The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: The QUMwatch study

Abstract

Most research into medication safety has been conducted in hospital settings with less known about primary care. The aim of this study was to characterise the nature and causes of medication incidents (MIs) in the community using a pharmacy incident reporting programme.Methods: Thirty community pharmacies participated in an anonymous or confidential MI spontaneous reporting programme in Sydney, Australia. The Advanced Incident Management System was used to record and classify incident characteristics, contributing factors, severity and frequency ratings.Results: In total, 1013 incidents were reported over 30 months, 831 of which were near misses while 165 reports involved patient harm. The largest proportion of cases pertained to patients aged >65 years (35.7%). Most incidents involved errors during the prescribing stage (61.1%), followed by dispensing (25.7%) and administration (23.5%), while some errors occurred at multiple stages (17.9%). Systemic antibacterials (12.2%), analgesics (11.8%) and renin-angiotensin medicines (11.7%) formed the majority of implicated classes. Participants identified diverse and interrelating contributing factors: those concerning healthcare providers included violations to procedures/guidelines (75.6%), rule-based mistakes (55.6%) and communication (50.6%); those concerning patients included cognitive factors (31.9%), communication (25.5%) and behaviour (6.1%). Organisational safety culture and inadequate risk management processes were rated as suboptimal. Conclusion:An MI reporting programme can capture and characterise medication safety problems in the community and identify the human and system factors that contribute to errors. Since medicine use is ubiquitous in the community, morbidity and mortality from MIs may be reduced by addressing the prioritised risks and contributing factors identified in this study.

Analysis of Medication Errors Reported by Community Pharmacists in the Republic of Korea: A Cross-Sectional Study

“…In line with previous reports, the most prevalent types of MEs in our study were “dosing error” and “wrong drug” [ 6 , 21 , 27 ]. Previous studies that analyzed dispensing errors of community pharmacists showed that incorrect doses, drugs, and quantities were the most frequently reported types of errors [ 28 ].…”

“…In this nationwide cross-sectional study, we analyzed MEs reported by community pharmacists. We found that most of the reported MEs occurred during the prescription process, consistent with the reports of previous studies [ 20 , 21 , 22 ]. These findings might have been affected by the reporters, mainly pharmacists, and outpatient settings.…”

“…Similarly to previous studies that analyzed ME reporting data [ 21 , 29 ], most reported MEs were near misses. This finding suggests that community pharmacists play an important role in preventing errors from reaching patients by intervening at the level of prescription errors with close to 90% effectiveness [ 30 ].…”

Detection and Prevention of Medication Errors by the Network of Sentinel Pharmacies in a Southern European Region

“…The drugs most frequently implicated in reported ME cases were beta-lactam antibiotics (5.0%), followed by antithrombotic agents (4.6%). These findings are similar to those of a study conducted in Australia, where systemic antibiotics was the therapeutic group most involved in MEs [30].…”

“…The data suggest that an incorrect, incomplete, illegible, or verbal medical prescription, followed by an incorrect dose, were the primary causes of MEs detected in community pharmacies in Catalonia. This has also been observed by other international studies that analyzed in depth the MEs detected during the dispensing process, as well as quality-related events [5,18,19,22,[30][31][32][33].…”