title: Medication safety in the home care setting: Development and piloting of a Critical Incident Reporting System
abstract: Background: While drug-related problems are among the most frequent adverse events in health care, little is known about their type and prevalence in home care in the current literature. The use of a Critical Incident Reporting System (CIRS), known as an economic and efficient tool to record medication errors for subsequent analysis, is widely implemented in inpatient care, but less established in ambulatory care. Recommendations on a possible format are scarce. A manual CIRS was developed based on the literature and subsequently piloted and implemented in a Swiss home care organization. Aim: The aim of this work was to implement a critical incident reporting system specifically for medication safety in home care. Results: The final CIRS form was well accepted among staff. Requiring limited resources, it allowed preliminary identification and trending of medication errors in home care. The most frequent error reports addressed medication preparation at the patients’ home, encompassing the following errors: omission (30 %), wrong dose (17.5 %) and wrong time (15 %). The most frequent underlying causes were related to working conditions (37.9 %), lacking attention (68.2 %), time pressure (22.7 %) and interruptions by patients (9.1 %). Conclusions: A manual CIRS allowed efficient data collection and subsequent analysis of medication errors in order to plan future interventions for improvement of medication safety. The development of an electronic CIRS would allow a reduction of the expenditure of time regarding data collection and analysis. In addition, it would favour the development of a national CIRS network among home care institutions.
authors.affiliation: 1 Klinische Pharmazie & Epidemiologie, Departement Pharmazeutische Wissenschaften, Universität Basel, Schweiz.
authors.forename: Carla
authors.initials: C
authors.lastname: Meyer-Massetti
authors.affiliation: 2 Pharmaceutical Care Research Group, Departement Pharmazeutische Wissenschaften, Universität Basel, Schweiz.
authors.forename: Evelyne
authors.initials: E
authors.lastname: Krummenacher
authors.affiliation: 3 Spitex Stadt Luzern, Schweiz.
authors.forename: Barbara
authors.initials: B
authors.lastname: Hedinger-Grogg
authors.affiliation: 4 Dienststelle Gesundheit, Gesundheitsdepartement des Kantons Luzern, Schweiz.
authors.forename: Stephan
authors.initials: S
authors.lastname: Luterbacher
authors.affiliation: 2 Pharmaceutical Care Research Group, Departement Pharmazeutische Wissenschaften, Universität Basel, Schweiz.
authors.forename: Kurt E
authors.initials: KE
authors.lastname: Hersberger
mesh_terms: D003625:Data Collection / Q000379:methods; D006699:Home Care Services; D006801:Humans; D050316:Medical Order Entry Systems / Q000458:organization & administration; D008508:Medication Errors / Q000451:nursing* / Q000517:prevention & control*; D010865:Pilot Projects; D058996:Quality Improvement / Q000458:organization & administration; D012307:Risk Factors; D013557:Switzerland; D013647:Task Performance and Analysis
keywords: CIRS; Critical Incident Reporting; Home Care; Medikationsfehler; Medikationssicherheit; ambulante Versorgung; ambulatory care; critical incident reporting; home care; medication error; medication safety