Factors Related to Medication Administration Incidents in England and Wales Between 2007 and 2016: A Retrospective Trend Analysis.
Journal
Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393
Informations de publication
Date de publication:
01 12 2021
01 12 2021
Historique:
pubmed:
14
3
2020
medline:
19
2
2022
entrez:
14
3
2020
Statut:
ppublish
Résumé
The aims of the study were to describe medication administration incidents reported in England and Wales between 2007 and 2016, to identify which factors (reporting year, type of incident, patients' age) are most strongly related to reported severity of medication administration incidents, and to assess the extent to which relevant information was underreported or indeterminate. Medication administration incidents reported to the National Reporting & Learning System between January 1, 2007, and December 31, 2016 were obtained. Characteristics of the data were described using frequencies, and relationships between variables were explored using cross-tabulation. A total of 517,384 incident reports were analyzed. Of these, 97.1% (n = 502,379) occurred in acute/general hospitals, mostly on wards (69.1%, n = 357,463), with medicine the most common specialty area (44.5%, n = 230,205). Medication errors were most commonly omitted doses (25.8%, n = 133,397). The majority did not cause patient harm (83.5%, n = 432,097). When only incidents causing severe harm or death (n = 1,116) were analyzed, the most common type of error was omitted doses (24.1%). Most incidents causing severe harm or death occurred in patients aged 56 years or older. For the 10-year period, the percentage of incidents with "no harm" increased (74.1% in 2007 to 86.3% in 2016). For some variables, data were often missing or indeterminate, which has implications for data analysis. Medication administration incidents that do not cause harm are increasingly reported, whereas incidents reported as severe harm and death have declined. Data quality needs to be improved. Underreporting and indeterminate data, inaccuracies in reporting, and coding jeopardize the overall usefulness of these data.
Identifiants
pubmed: 32168268
pii: 01209203-202112000-00031
doi: 10.1097/PTS.0000000000000639
doi:
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
e850-e857Informations de copyright
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Références
WHO. Medication without harm: WHO’s third global patient safety challenge. Available at: http://www.who.int/patientsafety/medication-safety/en/ . Accessed June 10, 2018.
Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Institute of Medicine (US) Committee on Quality of Health Care in America . Washington, DC: National Academies Press (US); 2000.
Leape LL. Reporting of adverse events. N Engl J Med . 2002;347:1633–1638.
Savage SW, Schneider PJ, Pedersen CA. Utility of an online medication-error-reporting system. Am J Health Syst Pharm . 2005;62:2265–2270.
NRLS. NaPSIR quarterly data workbook up to June 2017. Data on patient safety incidents reported to the NRLS up to June 2017. Available at: https://improvement.nhs.uk/resources/national-patient-safety-incident-reports-september-2017/ . Accessed August 3, 2018.
Panesar SS, Warner B, Sheikh A. Incident reporting and feedback approaches. In: Tully MP, Franklin BD, eds. Safety in Medication Use . Boca Raton, FL: CRC Press; 2016:157–170.
Howell AM, Burns EM, Bouras G, et al. Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System Data. PLoS One . 2015;10:e0144107.
Westbrook JI, Duffield C, Li L, et al. How much time do nurses have for patients? A longitudinal study quantifying hospital nurses’ patterns of task time distribution and interactions with health professionals. BMC Health Serv Res . 2011;11:319.
Antinaho T, Kivinen T, Turunen H, et al. Nurses’ working time use - how value adding it is? J Nurs Manag . 2015;23:1094–1105.
Drach-Zahavy A, Somech A, Admi H, et al. (how) do we learn from errors? A prospective study of the link between the ward’s learning practices and medication administration errors. Int J Nurs Stud . 2014;51:448–457.
McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication administration error rates. BMJ Qual Saf . 2013;22:278–289.
Raban MZ, Westbrook JI. Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review. BMJ Qual Saf . 2014;23:414–421.
Keers RN, Williams SD, Cooke J. Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence. Drug Saf . 2013;36:1045–1067.
Härkänen M, Ahonen J, Kervinen M, et al. The factors associated with medication errors in adult medical and surgical inpatients: a direct observation approach with medication record reviews. Scand J Caring Sci . 2015;29:297–306.
NPSA. 2007. Safety in doses: medication safety incidents in the NHS 2007. Available at: http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61392 . Accessed June 11, 2018.
Cousins DH, Gerrett D, Warner B. A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005-2010). Br J Clin Pharmacol . 2012;74:597–604.
WHO. Medication errors. Technical series on safer primary care. Available at: http://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf;jsessionid=2C5F14D40CBFE11B2D4CC3A0B130396C?sequence=1 . Accessed June 12, 2018.
NCCMERP. The National Coordinating Council for medication error reporting and prevention. Medication errors – definition. Available at: http://www.nccmerp.org/about-medication-errors . Accessed June 12, 2018.
Parry AM, Barriball KL, While AE. Factors contributing to registered nurse medication administration error: a narrative review. Int J Nurs Stud . 2015;52:403–420.
Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm . 2011;68:227–240.
Noble DJ, Pronovost PJ. Underreporting of patient safety incidents reduces health care’s ability to quantify and accurately measure harm reduction. J Patient Saf . 2010;6:247–250.
Mahajan RP. Critical incident reporting and learning. Br J Anaesth . 2010;105:69–75.
Elliott RA, Camacho E, Campbell F, et al. Prevalence and economic burden of medication errors in the NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. Policy Research Unit in Economic Evaluation of Health & Care Interventions (EEPRU) . 2018. Available at: http://www.eepru.org.uk/wp-content/uploads/2018/02/eepru-report-medication-error-feb-2018.pdf . Accessed June 14, 2018.
Holmström AR, Airaksinen M, Weiss M, et al. National and local medication error reporting systems: a survey of practices in 16 countries. J Patient Saf . 2012;8:165–176.
Mitchell I, Schuster A, Smith K, et al. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘to err is human’. BMJ Qual Saf . 2016;25:92–99.
Stavropoulou C, Doherty C, Tosey P. How effective are incident-reporting systems for improving patient safety? A systematic literature review. Milbank Q . 2015;93:826–866.
Hartnell N, MacKinnon N, Sketris I, et al. Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study. BMJ Qual Saf . 2012;21:361–368.
Panesar SS, Noble DJ, Mirza SB, et al. Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics?—can the checklist help? Supporting evidence from analysis of a national patient incident reporting system. J Orthop Surg Res . 2011;6:18.
Donaldson LJ, Panesar SS, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a National Database, 2010–2012. PLoS Med . 2014;11:e1001667.
Williams SD, Ashcroft DM. Medication errors: how reliable are the severity ratings reported to the national reporting and learning system? Int J Qual Health Care . 2009;21:316–320.
Sevdalis N, Jacklin R, Arora S, et al. Diagnostic error in a national incident reporting system in the UK. J Eval Clin Pract . 2010;16:1276–1281.
Renshaw M, Vaughan C, Ottewill M, et al. Clinical incident reporting: wrong time, wrong place. Int J Health Care Qual Assur . 2008;21:380–384.
NHS Improvement. National patient safety incident reports: 2017. Available at: https://improvement.nhs.uk/resources/national-patient-safety-incident-reports-september-2017 . Accessed June 12, 2018.
NRLS reporting e-form. Available at: https://www.eforms.nrls.nhs.uk/staffreport/incident_report.jsp . Accessed June 12, 2018.
NRLS national patient safety incident reports: commentary March 2018. Available at: https://improvement.nhs.uk/documents/2543/NAPSIR_commentary_FINAL_data_to_December_2017.pdf . Accessed May 28, 2019.
NRLS. 2018b. About reporting patient safety incidents. Available at: http://www.nrls.nhs.uk/report-a-patient-safety-incident/about-reporting-patient-safety-incidents/ . Accessed June 12, 2018.
NHS Improvement. Guidance notes on National Reporting and Learning System quarterly data summary publications. 22 March 2017. Available at: https://improvement.nhs.uk/documents/834/QDS_GUIDE_TO_MAR17.pdf . Accessed May 28, 2019.
NHS England. Patient safety alert. Improving medication error incident reporting and learning. 20 March 2014. Available at: https://www.england.nhs.uk/wp-content/uploads/2014/03/psa-sup-info-med-error.pdf . Accessed June 7, 2018.
Franklin BD, Panesar SS, Vincent C, et al. Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids. BMJ Qual Saf . 2014;23:765–772.
Vincent C. Incident reporting and patient safety. BMJ . 2007;334:51.