Identifying medication error chains from critical incident reports: a new analytic approach.
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.
Luzerner Kantonsspital, Quality and Risk Management, Lucerne, Switzerland.
Saskia
S
Huckels-Baumgart
Tanja
T
Manser
D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology*; D006784:Hospitals, Teaching; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008510:Medication Systems, Hospital / Q000458:organization & administration* / Q000592:standards; D004364:Pharmaceutical Preparations / Q000008:administration & dosage; D013557:Switzerland
D004364:Pharmaceutical Preparations
incident analysis; medication error; medication error chains; medication use process