Background and importance Evidence regarding the rate of medication errors (ME) and adverse drugs events (ADE) during the COVID-19 pandemic is limited. In that period the risk of ME and unsafe medication practices was potentially higher than average. Thus, voluntary hospital reporting systems are valuable sources of information on ME and ADE.
Aim and objectives To describe the ME and ADE registered in the voluntary electronic notification system of our centre (TPSC Cloud) during the first year of the COVID-19 pandemic and compare them with the same period in the previous year.
Material and methods A retrospective observational study of ME and AE notifications in the TPSC Cloud from March 2020 to February 2021 compared to notifications recorded from March 2019 to February 2020.
Five types of incidents were differentiated: situations with the capacity to cause ME, ME that do not reach the patient, ME that reach the patient without ADE, ME with ADE, and ADE without ME. The drugs involved in those incidents and the professional notifier also were identified.
Results 249 incidents were reported from March 2020 to February 2021, which was 31.02% less than in the previous period (n=361) from March 2019 to February 2020. The most common ME was prescription error in both periods (70.4% vs 67.3%). The incident profile by typology was similar in both periods. The most frequent was ME that did not reach the patient (40.24% vs 43.47%), followed by ME that reached the patient without ADE (23.42% vs 28.53%). Systemic anti-infectives drugs were the most involved in both periods (n=57; 22.89% vs n=73; 20.22%).
84 ADE without ME were reported from March 2020 to February 2021, representing an increase of 500% compared with March 2019 to February 2020 (n=14). Emphasising the notification of 35 ADE of lopinavir/ritonavir and 4 of hydroxychloroquine used in the initial treatment of COVID-19.
The main notifier in both periods was the pharmacist (80.48% vs 65.60%).
Conclusion and relevance During the first COVID-19 pandemic year, notifications of ME decreased, due to care load pressure, but incident profile was similar. Otherwise, ADE notifications increased notably, due to active pharmacovigilance carried out by pharmacists on off-label drugs used to treat COVID-19.
Conflict of interest No conflict of interest
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