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PS-043 Analysis and Prevention of medication errors in patients with renal impairment
  1. P Kantelhardt1,
  2. MJ Hug2,
  3. G Picksak3
  1. 1Universitätsmedizin Mainz, Neurochirurgie, Mainz, Germany
  2. 2Universitätsklinikum Freiburg, Apotheke, Freiburg, Germany
  3. 3Medizinische Hochschule Hannover, Zentralapotheke, Hannover, Germany


Background There is evidence from the literature that medicines errors (ME) frequently occur in patients with impaired renal function. Reporting systems can be used to understand better the causes of such ME and to develop targeted prevention strategies. The DokuPIK error reporting system, developed by the German Society of Hospital Pharmacists, is able to perform analyses that can be narrowed down to specific subgroups.

Purpose To identify which active substances and which error types are most frequently associated with patients suffering from renal impairment. The results may be useful to develop appropriate prevention strategies.

Materials and methods For our analysis, all data sets entered into DokuPik between October 2008 and March 2013 were restricted to entries in which a renal impairment was indicated. From this pool of data the active substances, types of errors and their respective causes were extracted and categorised. The problems identified by this method were ranked for frequency and prevention strategies were deduced accordingly.

Results From a total of 16,808 entries 2,733 sets of data contained information on patients with renal impairment. Active substances most frequently associated with this subgroup were ramipril (75), levofloxacin (58), ibuprofen (53), simvastatin (46) and enoxaparin (46). The most common types of error were dose adjustment (26%), contraindication (13%), interaction (10%) and single or total dose (9%). Of the total number of reports on dose adjustment (n = 1084) a significant proportion (852 = 78%) was associated with renal impairment. The most common reasons for the ME were insufficient knowledge (66%), work overload (9%) and lack of organisation (4%).

Conclusions Our data confirm that impaired renal function is a risk factor with respect to ME. The most frequent error is related to missing or wrong dose adjustment. In addition we were able to identify a number of drugs that are more likely to be associated with ME. A better knowledge of all the factors involved in creating ME may be useful for developing customised prevention strategies. The design of drug-specific awareness posters could be a means of reminding all healthcare professionals to take extra care when prescribing and administering medicines to patients with impaired renal function.

No conflict of interest.

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