Magnitude of error: a review of wrong dose medication incidents reported to a UK hospital voluntary incident reporting system

Abstract

ObjectivesOur aim was to review medication-related incidents reported to a hospital voluntary incident reporting system to identify and quantify the magnitude of wrong dose errors.MethodsThe study was a retrospective review of medication-related incidents reported over a 7-year period at a large acute teaching hospital in the UK, providing secondary and tertiary care for a range of clinical specialties. Medication-related incident reports submitted from all clinical settings were reviewed. Incidents submitted under the categories ‘wrong dose’, ‘wrong dose preparation’, ‘wrong rate’ or ‘wrong quantity’ and describing situations where incorrect doses were prescribed, dispensed or administered were analysed. Magnitudes of medication overdoses and underdoses reported from adult and paediatric settings were calculated. Stage of the medicines process and drug classes most commonly involved in wrong dose errors were described.ResultsOf 12 006 reported medication incidents, 1568 described ‘wrong-dose’ errors: 702 (44.8%) were prescribing errors, 223 (14.2%) were dispensing errors and 643 (41%) were administration errors. Overdoses were reported more frequently than underdoses. 926 (59%) of reported wrong dose errors were overdoses, 464 (29.6%) were underdoses; the magnitude could not be determined in 178 (11.4%) of reports. Twofold and 10-fold overdoses and underdoses were the most commonly reported error magnitude, although dosing errors across a wide range of magnitudes were reported. Incidents were reported from paediatric wards (491, 31.3%), non-paediatric wards and clinical settings (880, 56.1%) and pharmacy (197, 12.6%). Prescribing errors (702, 45.9%) were reported more commonly than administration (643, 41%) and dispensing errors (223, 14.2%). Drugs acting on the central nervous system, cardiovascular drugs and anti-infectives were the drug classes most commonly involved.ConclusionsWrong dose errors occur across all inpatient settings. Wrong dose errors of all magnitudes are possible, but twofold and 10-fold errors occur most frequently. Drug classes involved in wrong dose incidents reported to a voluntary reporting system in a large acute hospital are similar to those identified using other methodologies. Harms and potential harms associated with specific drugs and error magnitudes need to be identified to inform quality improvement work to reduce the risk of patient harm.

Residual Volume of Ampoule-Vials and Underdosing of Medications Prepared by a Nursing Staff

“…It is worth mentioning that overdoses are more likely to be identified, intercepted, and reported than underdoses, as they can be perceived as having greater potential for patient harm. However, all drug doses should be prescribed in accordance with clinical guidance and dispensed and administered exactly as prescribed, since the potential for patient harm associated with dosing errors is difficult to predict and varies according to a number of factors, including the magnitude of the error, the toxicity profile of the drug itself, the clinical status of the patient, and the tolerance or susceptibility to the effect of the drug 27 .…”

Volume Residual De Frascos-Ampola E Subdosagens De Medicamentos Preparados Pela Equipe De Enfermagem

“…É interessante mencionar que sobredosagens são mais prováveis de serem identificadas, interceptadas e notificadas que as subdosagens, pois podem ser percebidas como tendo maior potencial de dano ao paciente. Contudo, todas as doses de medicamentos devem estar prescritas de acordo com a orientação clínica e ser dispensadas e administradas exatamente como prescrito, uma vez que o potencial de dano ao paciente associado a erros de dose é difícil de prever e varia de acordo com uma série de fatores, incluindo a magnitude do erro, o perfil de toxicidade do próprio medicamento, o estado clínico do paciente e a tolerância ou suscetibilidade ao efeito do medicamento 27 .…”

Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system

“…Evidence suggests that medication errors are more likely to occur in children than in adults and may be up to three times more likely to cause harm 3–5. Voluntary incident reporting has been used to monitor medication errors and related patient safety risks in hospitals around the world 6 7. A retrospective study of medication errors in children submitted to the US Pharmacopeia’s Medication Errors Reporting Program found that 31% of the errors were cited as harmful or fatal 8…”