Marja Härkänen1, Katri Vehviläinen-Julkunen2, Trevor Murrells3, Anne Marie Rafferty4, Bryony Dean Franklin5. 1. University of Eastern Finland: Department of Nursing Science, Academy of Finland, Yliopistoranta 1c, Kuopio, Finland. Electronic address: marja.harkanen@uef.fi. 2. University of Eastern Finland: Department of Nursing Science, Kuopio University Hospital, Yliopistoranta 1c, Kuopio, Finland. Electronic address: katri.vehvilainenjulkunen@uef.fi. 3. King's College London: Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK. Electronic address: trevor.murrells@kcl.ac.uk. 4. King's College London: Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK. Electronic address: anne_marie.rafferty@kcl.ac.uk. 5. Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London/UCL School of Pharmacy, London, UK. Electronic address: bryony.franklin@nhs.net.
Abstract
BACKGROUND: Medication administration errors may contribute to patient mortality, thus additional understanding of such incidents is required. OBJECTIVES: To analyse medication administration errors reported in acute care resulting in death, to identify the drugs concerned, and to describe medication administration error characteristics (location of error, error type, patient's age) by drug group. METHODS: Medication administration errors reported in acute care in 2007 ̶ 2016 (n = 517,384) were obtained from the National Reporting and Learning System for England and Wales. Incidents reported as resulting in death (n = 229) were analysed. Drugs were classified by two researchers using the British National Formulary. Drug categories were described by medication administration errors' year, location, patient age, and error category based on the incidents' original classification. RESULTS: Errors were most often reported on wards (66.4%, n = 152), and in patients aged over 75 years (41.5%, n = 95). The most common error category was omitted medicine or ingredient (31.4%, n = 72); most common drug groups were cardiovascular (20.1%, n = 46) and nervous system (10.0%, n = 23). Most errors in patients under 12 years concerned drugs to treat infection; cardiovascular drugs were most common among other age groups. CONCLUSIONS: In order to prevent these most serious of medication administration errors, interventions should focus on avoiding dose omissions, and administration of drugs for patients over 75 years old, as well as safe administration of parenteral anticoagulants and antibacterial drugs.
BACKGROUND: Medication administration errors may contribute to patientmortality, thus additional understanding of such incidents is required. OBJECTIVES: To analyse medication administration errors reported in acute care resulting in death, to identify the drugs concerned, and to describe medication administration error characteristics (location of error, error type, patient's age) by drug group. METHODS: Medication administration errors reported in acute care in 2007 ̶ 2016 (n = 517,384) were obtained from the National Reporting and Learning System for England and Wales. Incidents reported as resulting in death (n = 229) were analysed. Drugs were classified by two researchers using the British National Formulary. Drug categories were described by medication administration errors' year, location, patient age, and error category based on the incidents' original classification. RESULTS: Errors were most often reported on wards (66.4%, n = 152), and in patients aged over 75 years (41.5%, n = 95). The most common error category was omitted medicine or ingredient (31.4%, n = 72); most common drug groups were cardiovascular (20.1%, n = 46) and nervous system (10.0%, n = 23). Most errors in patients under 12 years concerned drugs to treat infection; cardiovascular drugs were most common among other age groups. CONCLUSIONS: In order to prevent these most serious of medication administration errors, interventions should focus on avoiding dose omissions, and administration of drugs for patients over 75 years old, as well as safe administration of parenteral anticoagulants and antibacterial drugs.
Authors: Marja Härkänen; Jussi Paananen; Trevor Murrells; Anne Marie Rafferty; Bryony Dean Franklin Journal: BMC Health Serv Res Date: 2019-11-04 Impact factor: 2.655