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PS-001 Identification of risk factors frequently associated with medication errors – pan-european project for patient safety (peppas)
  1. P Kantelhardt1,
  2. A Süle2,
  3. M Saar3,
  4. T Gudmundsdottir4,
  5. AG Märtson3
  1. 1ADKA, 10559 Berlin, Germany
  2. 2Peterfy Hospital and Trauma Center, Hospital Pharmacy, Budapest, Hungary
  3. 3Tartu University Hospital, Hospital Pharmacy, Tartu, Estonia
  4. 4Landspitali – The National University Hospital of Iceland LSH, Hospital Pharmacy, Reykjavik, Iceland

Abstract

Background Medication errors are a major problem for patient safety all over Europe. To avoid medication errors, a better knowledge of the respective risk factors as well as the type of errors and causes are necessary.

Purpose With documentation of medication errors and later identification of risk factors, we invented the PEPPAS to detect major risk, learn from other countries and share strategies to avoid medication errors.

Material and methods We invented the German medication error reporting system DokuPIK in Iceland, Estonia and Hungary. In these critical incident reporting system reports could be submitted online. Apart from a standalone use in a single hospital, it can also be used nationwide as well as internationally to detect major risk. These records were inputted into the database by pharmacists and pharmaceutical technicians. They were free to put in all errors they thought were worth reporting. Data were exported into MS Excel and screened independently by a hospital pharmacist. Entries were categorised for frequency of type of error, cause of error and degree of severity caused by the medication error.

Results The present pilot study is based on analysis of 1522 records stored in the DokuPIK (November 2014 to February 2015). The analysis revealed the following rank order of types of error: (wrong) dose (250), clear indication but no drug prescribed (155) and interactions (140). The most common causes were identified as: lack of knowledge (737), organisation (380) and workload (361). Most of the errors were classified as “an error occurred, reached the patient but did not cause patient harm”.

Conclusion Based on our present data, we are already able to identify a number of risk factors that most likely cause medication errors. There is only a small bias in the system, caused by the reporting colleagues. They have to decide which errors to report. With this information we have a means of developing specific strategies to avoid medication errors while keeping human and financial resources at an optimum by sharing knowledge all over Europe. The database should be enrolled in more European countries in the future to gain more data.

No conflict of interest.

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