Article Text

Download PDFPDF
PS-011 Identifying and reporting medication errors: learning from other countries
  1. P Kantelhardt1,
  2. A Süle2,
  3. M Saar3,
  4. AG Raadom3,
  5. TK Gudmundsdottir4
  1. 1ADKA eV, Working Group Medication Safety, Berlin, Germany
  2. 2Peterfy Hospital, Pharmacy, Budapest, Hungary
  3. 3Tartu University Hospital, Pharmacy, Tartu, Estonia
  4. 4Landspitali, Pharmacy, Reykjavik, Iceland


Background It is important to identify medication errors (MEs) in the healthcare system in order to be able to prevent them. Is there a possibility to combine forces and transfer strategies between countries?

Purpose Based on analyses of data in a defined medication error reporting system (MERS), strategies were shaped to reduce MEs. Further investigations looked for similarities in MEs from other countries to develop ways of transferring existing strategies between different healthcare systems.

Material and methods MEs were reported in an MERS from November 2014 to July 2016 in 4 (European) countries. The reported data were exported to Microsoft Excel and analysed for type and cause of error reported. The participating countries were compared, finding similarities. Existing strategies preventing MEs developed in one of the countries were discussed to outline possible ways to transfer them.

Results During the reporting period, 7107 MEs on every level were reported. The most frequent type of errors were reported in the areas of ‘administration’ and ‘drug formulation’, including preparation before application (7.6%). These were prevalent types of MEs in 3 of the 4 countries. Frequent problems were crushing or dividing of solid oral drug formulations, even modified release-systems. Mostly related drugs were modified release oral systems containing opioids, isosorbidemononitrate or metoprolol, mirtazapine in orally disintegrating tablets and proton pump inhibitors. In one of the countries a former analysis identified numerous reports with crushed or divided proton pump inhibitor tablets as well as crushed or divided modified release opioid drug formulations. Mostly there was ‘lack of knowledge’ as the leading cause of these errors, similar in 2 more countries. Therefore, there was a need to transfer established strategies to these countries. In these countries, a poster was made about the risks arising from crushing and dividing to raise awareness among healthcare professionals and patients. This poster has now been translated into English and can be easily transferred to project partners.

Conclusion Results from this analysis has enabled pharmacists to recognise similarities between countries. Based on these, opportunities were identified to transfer strategies between countries. Furthermore, it is essential to look for additional areas to compare and analyse in order to outline ‘best practices’ as transfer strategies between countries.

No conflict of interest

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.