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General and Risk Management, Patient Safety (including: medication errors, quality control)
Analysis of medication errors in a private hospital: pharmacist interventions
  1. J. Fernández Morató,
  2. A. González Ruiz,
  3. P. Alonso Castell,
  4. L. Vilalta Sabartés,
  5. F. Pertíñez Sansón,
  6. S. Roig Pérez
  1. 1Centro Médico Teknon, Pharmacy, Barcelona, Spain

Abstract

Background The medication errors (ME) represent the largest single cause of errors in the hospital setting, and some of them result in serious patient morbidity/mortality. A knowledge of ME in every hospital would lead to improve pharmacotherapy process and patient safety.

Purpose To describe and analyse ME reported in our hospital and quantified pharmacist interventions.

Materials and methods The site of the study was a 300-bed private hospital, accredited by the Joint Commission of International. The report of ME detected in inpatients was extracted as Excel files from January to September 2011 and included: drug involved, description of the event, cause of error, patient consequences and health professional who reported the ME. The pharmacists report ME and make interventions reviewing all the prescriptions in a Computerised Physician Order Entry.

Results During the study period 213 ME were reported (0, 78 ME/day–0.044% of total prescriptions). The main class of drug involved in ME were anti-infective agents (108; 50, 7%). The most frequent types of ME were: 69 (32, 4%) overdosage (30 in renal impairment), 41 (19, 2%) underdosage, 23 (10, 8%) inadequate schedule, 21 (9, 9%) wrong drug and 16 (7, 5%) drug omission. The wrong prescription was the main cause of ME (165; 77, 5%). The pharmacists were the health professionals who reported most of the ME (167; 78, 4%), with 140 interventions carried out (83, 8% of total ME reported by the pharmacists). The 75, 7% of interventions were accepted. Classification by the reporters were: 134 (62, 9%) reached the patient and did not cause harm, 69 (32, 4%) did not reach the patient, 8 (3, 8%) required health monitoring and 2 (0, 9%) resulted in temporary harm (one required medical treatment and the other required prolonged hospitalisation).

Conclusions Real and potential ME in inpatients can be identified mainly reviewing drug prescriptions by the pharmacists. The most of interventions are focused in wrong anti-infective dosages. Prevention strategies for ME deriving from analyses of the reports are contributing directly to patient safety.

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