What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system

Abstract

ObjectivesTo (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff.DesignAudit of 3291patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’.SettingTwo major academic teaching hospitals in Sydney, Australia.Main Outcome MeasuresRates of medication errors identified from audit and from direct observation were compared with reported medication incident reports.ResultsA total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit.ConclusionsPrescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.

Critical Incident Reporting System (CIRS): a fundamental component of risk management in health care systems to enhance patient safety

“…The occurrence of incidents with respect to organization and processes [16,17], surgery and anaesthesia [18][19][20], and medication [6,[20][21][22][23][24][25] were described, too.…”

“…One element is to ensure and promote effective work at all levels to increase patient safety. These can be mediated by education and training to increase the knowledge and skills of the staff [25,27,30]. Another aspect is the implementation of a "no blame" error and feedback culture and the security of an absolutely anonymous reporting system [4,37,41,44].…”

Learning from incidents in health care: Critique from a Safety-II perspective

“…Such barriers include, for example, fear of blame and repercussions, poor usability of incident reporting systems, perceptions among doctors that incident reporting is a nursing process, lack of feedback to staff who report incidents, and lack of visible improvements to the local work environment as a result of reported incidents (Benn et al, 2009, Braithwaite et al, 2010, Lawton and Parker, 2002, Macrae, 2015, Sujan, 2012, Sujan et al, 2011a. Among management staff in particular, there continues to be widespread misperception that incident reporting systems might be useful for monitoring incident frequencies, despite evidence that suggests that incident reporting data are poor indicators of actual incident frequencies (Westbrook et al, 2015). It has been suggested that the focus of learning from incidents in health care has been too much on collecting and categorising data (Macrae, 2015, Anderson andKodate, 2015), whereas successful learning from experience should inherently be a social and participative process (Macrae, 2015, Lukic et al, 2012.…”

Implementing Healthcare Improvement

“…Among management staff in particular, there continues to be widespread misperception that incident reporting systems might be useful for monitoring incident frequencies, despite evidence that suggests that incident reporting data are poor indicators of actual incident frequencies [74].…”