The Risks and Outcomes Resulting From Medication Errors Reported in the Finnish Tertiary Care Units:

Abstract

Background: Hospital-acquired medication errors (MEs) are common in health care. Although voluntary reporting is criticized for not producing reliable estimates on ME frequency, it provides valuable knowledge on errors occurring in the medication process. Objective: The purpose of this study was to analyze and determine the risks and outcomes resulting from MEs related to the TOP15 medicines in the Finnish tertiary care units from July 2016 to July 2017. Methods: The data consisting of 1,447 ME reports was organized according to ATC classification, after which TOP15 medicines involved in the reports were selected. Inductive content analysis was performed to the reports. After this, the reports were categorized by ME outcome into five categories and further analyzed accordingly. Results: The most common ME outcome in the reports was "omitted medicine" (33.9%). More than a quarter (27.1%) of ME reports were estimated to cause moderate or severe risk to the patient. When compared with each other, none of the outcome groups were more susceptible to high-risk events (p = 0.71). Of the TOP15 medicines, only Norepinephrine had significantly higher risk of being involved in high-risk events (OR 2.43, 95%CI 1.35-4.61). Conclusion: Voluntary reporting has an important role in the development of medication safety and the overall medication process within organizations. Although majority of the TOP15 medicines were involved in MEs resulting in seemingly high-risk outcomes, they were estimated to be insignificant or minor within the reporting unit. In the future, more emphasis will be needed for the assessment and analysis of the reports for more efficient, real-time detection and response to signals from health care units.

Drug related problems in clinical practice: a cross-sectional study on their prevalence, risk factors and associated pharmaceutical interventions

“…Interventions registers are essential, as in other healthcare areas, to document professional activity and to assess the suitability of the approach being taken to eventually improve healthcare outcomes 65 . Despite its possible benefits, registries of clinical pharmacy have normally been present in specific areas, such as those linked to a computerized DRP alert system or nationwide voluntary reporting systems 40 , 66 .…”

Prescribing errors among family and community medicine center in Riyadh, Saudi Arabia

“…The foregoing reason was previously reported by Ross et al (2012). Most of the patients visiting the community center are diabetic or hypertensive or both, in addition to other cardiovascular diseases, which might explain the high frequency of prescribing errors on diabetic and cardiovascular medications (Laatikainen et al, 2020;Safholm et al, 2019). Other reported reasons pertain to prescribers not using current available treatment evidence or available patient information (allergy information, other medications, and other conditions).…”

Norepinephrine medication errors: the solution is in the solution, but shape shifting may help

“…Analysis of drug errors occurring in the tertiary care setting within a national reporting system showed norepinephrine was ''the only medicine with significantly higher frequency for incidents that were assessed to cause moderate or severe risk to the patient (odds ratio 2.43, 95% confidence interval 1.35 to 4.61).'' 2 Interestingly, this study further identified error etiology noting ''that the majority of the reported events involving norepinephrine were related to administration of wrong medicine due to look alike errors''. 2 Using our established Quality and Patient Safety (QPS) Committee processes, 3 discussion and contextualization of these findings highlighted similarities with norepinephrine near-miss drug error events at our institution: lookalike circumstances with other commonly available and administered perioperative medications (e.g., fentanyl and dexamethasone).…”

“…2 Interestingly, this study further identified error etiology noting ''that the majority of the reported events involving norepinephrine were related to administration of wrong medicine due to look alike errors''. 2 Using our established Quality and Patient Safety (QPS) Committee processes, 3 discussion and contextualization of these findings highlighted similarities with norepinephrine near-miss drug error events at our institution: lookalike circumstances with other commonly available and administered perioperative medications (e.g., fentanyl and dexamethasone). From the photos below, the risk for lookalike vial medication error involving fentanyl, dexamethasone, and norepinephrine is apparent (Figure).…”