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Identifying medication error chains from critical incident reports: A new analytic approach
Author(s) -
HuckelsBaumgart Saskia,
Manser Tanja
Publication year - 2014
Publication title -
the journal of clinical pharmacology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.92
H-Index - 116
eISSN - 1552-4604
pISSN - 0091-2700
DOI - 10.1002/jcph.319
Subject(s) - medication error , medicine , incident report , patient safety , near miss , documentation , process (computing) , emergency medicine , medical emergency , computer science , reliability engineering , health care , computer security , engineering , economics , programming language , economic growth , operating system
Research into the distribution of medication errors usually focuses on isolated stages within the medication use process. Our study aimed to provide a novel process‐oriented approach to medication incident analysis focusing on medication error chains . Our study was conducted across a 900‐bed teaching hospital in Switzerland. All reported 1,591 medication errors 2009–2012 were categorized using the Medication Error Index NCC MERP and the WHO Classification for Patient Safety Methodology. In order to identify medication error chains, each reported medication incident was allocated to the relevant stage of the hospital medication use process. Only 25.8% of the reported medication errors were detected before they propagated through the medication use process. The majority of medication errors (74.2%) formed an error chain encompassing two or more stages. The most frequent error chain comprised preparation up to and including medication administration (45.2%). “Non‐consideration of documentation/prescribing” during the drug preparation was the most frequent contributor for “wrong dose” during the administration of medication. Medication error chains provide important insights for detecting and stopping medication errors before they reach the patient. Existing and new safety barriers need to be extended to interrupt error chains and to improve patient safety.