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A computerized system for reporting medication events in psychiatry: the first two years of operation
Author(s) -
HAW C.,
CAHILL C.
Publication year - 2011
Publication title -
journal of psychiatric and mental health nursing
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.69
H-Index - 63
eISSN - 1365-2850
pISSN - 1351-0126
DOI - 10.1111/j.1365-2850.2010.01664.x
Subject(s) - medicine , near miss , psychiatry , adverse drug event , medication error , incident report , distraction , adverse effect , medical emergency , patient safety , drug , emergency medicine , health care , psychology , computer security , computer science , forensic engineering , neuroscience , engineering , economics , economic growth
Accessible summary• Use of a computerized medication error reporting system led to a large increase in the number of errors reported. • Most of the errors reported were medication administration errors. Most were not serious. • The most common error types were missing signature and omission of a drug without valid clinical reason. • Analysis of error reports may help reduce further errors thereby improving patient care.Abstract The aim of this paper is to describe the first 2 years of operation of an electronic system for reporting medication events in psychiatry (Medi‐Event system). We have carried out a descriptive analysis of all medication events (errors, near misses and adverse drug reactions) reported between 1 March 2008 and 28 February 2010 at a large, specialist UK psychiatric hospital. A total of 406 medication errors, 40 near misses and no adverse drug reactions were reported in the study period, representing a very large increase in reporting frequency with respect to the previous paper system. The majority (88.8%) of incidents were medication administration errors. The most common error types were failure to sign for a drug and omission of a drug without valid clinical reason. Although most errors were of minor severity, 6.3% were rated as moderate or serious. Distraction was cited as the most common contributory factor, also poor communication and being unfamiliar with the ward. In conclusion, use of the Medi‐Event system increased the reporting of medication errors. Analysis of the pattern of errors, as well as of contributory factors and suggestions for error prevention, may help reduce the frequency of medication events and hence improve patient care.