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PS-006 Identifying and reporting medication errors helps pharmacists to have a great role in promoting patient safety
  1. AG Märtson1,
  2. M Saar1,
  3. P Kantelhardt2
  1. 1Pharmacy of Tartu University Hospital, Pharmacy, Tartu, Estonia
  2. 2University Hospital of Mainz, Neurosurgery, Mainz, Germany


Background It is important to identify medication errors (MEs) in the health system in order to prevent them in the future. Pharmacists have the knowledge and experience to recognise MEs and to help with strategies to prevent MEs.

Purpose As the clinical pharmacy service is still being established in this country, error reporting and analysis was a good way for pharmacists to show their worth and also to get more involved in everyday clinical work. This study was a part of a cross country project.

Material and methods MEs were reported from November 2014 to June 2015 in a 900 bed hospital. An anonymous internet based error reporting system was developed in 2009, which was also used for this project. This had some pull down menus, free text options, different filters and search options. The data collected were: sex, age, renal and liver failure (if present), department (where ME occurred), the reporters department, location of error, type of error, cause of error and international system based classification of error. Data were exported to MS Excel and analysed by pharmacists.

Results During the reporting period 87 MEs were reported. The majority of MEs occurred in patients over 65 (44%), in surgery departments (29%) and most of the patients did not have renal or liver failure. The most frequent types of errors were documentation errors, dosing errors, contraindications and double prescriptions. 97% of errors were caused by lack of knowledge. The MEs were categorised according to severity into 6 groups. 42% of MEs were errors that reached the patient but did not cause patient harm and 36% of MEs were errors that reached the patient and required monitoring to confirm that it resulted in no harm to the patient.

Conclusion After this study the pharmacists were able to identify which wards had the most MEs and where could the clinical pharmacy service be implemented. As the majority of MEs were caused by lack of knowledge, this study encourages pharmacists to educate medical staff and develop local guidelines to avoid MEs in the future.

No conflict of interest.

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