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PS-083 Analysing medication errors reported: a basis for continuous improvement
  1. L Gutermann1,
  2. V Chenet2,
  3. E Camps1,
  4. B Bonan1
  1. 1Hôpital Foch, Pharmacy, Suresnes, France
  2. 2Hôpital Foch, Risk Management, Suresnes, France

Abstract

Background In France, the reporting, evaluation and prevention of medication errors (ME) are regulatory requirements for hospitals. This represents a key point in the risk management policy and the improvement of the quality of patient care. In our hospital, MEs are reported using electronic software (BLUEMEDI) to facilitate their declaration.

Purpose To analyse medication errors reported in order to identify ways of improvement.

Material and methods Quantitative and qualitative retrospective analysis of MEs reported from January 2010 to August 2014. The data were extracted from BLUEMEDI software and classified according to ME characteristics, contributing factors and their belonging to the national list of events that should never happen (“never events”).1 Multidisciplinary team work (MTW) has identified ways of improving.

Results 90 MEs were analysed. Most MEs were administration errors (AEs) (75.6%, n = 68) and only 22 (24.4%) were prescribing errors. Regarding the characteristics of AEs, there were 16 drugs errors, 15 administration technique errors, 10 dose errors, 7 drug omissions, 7 drug storage errors, 6 drug administration traceability errors, 5 patient errors, 2 drug preparation errors. Furthermore, 16 (23.5%) of these AEs were part of “never events”: 6 concerned anticoagulants, 5 insulin, 3 potassium chloride, 1 a paediatric solution. All of these “never events” were preventable and the human factor was involved in 14 (87.5%) of situations. To raise awareness among nursing staff about AEs, the MTW suggested implementing a play-based training scenario, error checking in a standardised patient room. Topics have been chosen from the “never events” that have occurred.

Conclusion Learning from our mistakes is one of the first steps towards a safer care system. This retrospective analysis allowed us to develop targeted training. Furthermore, establishing a training program based on error detection will not only raise nurses’ awareness of administration errors but also improve knowledge of them.

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