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5PSQ-040 Voluntary medication errors reporting system in an orthopaedic surgery and traumatology unit
  1. A Couso1,
  2. E Martinez Diaz1,
  3. A Pérez Plasencia1,
  4. S Garcia Rodicio1,
  5. N Ramón Rigau1,
  6. D Noriego Muñoz2,
  7. J Sugrañes Escribano2,
  8. M Bruguera Teixidor1,
  9. C Subirana Batlle1,
  10. A Dordà Benito1
  1. 1Hospital Universitari Dr. Josep Trueta, Pharmacy Department, Girona, Spain
  2. 2Hospital Universitari Dr. Josep Trueta, Orthopaedic Surgery Department, Girona, Spain


Background and Importance Medication errors (ME) are incidents that can occur at any stage of medication use in patient‘s care process. Voluntary incident reporting has proven to be a useful tool to identify contributing factors and establish improvement actions. Surgical patients have one of the highest rates of MEs because of their vulnerable profile and their multiple care transitions.

Aim and Objectives To analyse the voluntary ME notifications made in the Orthopedic surgery and Traumatology unit of a tertiary level hospital with electronic prescription, validation and administration system, to identify the most important contributing factors and to describe improvement actions.

Material and Methods ME reported in the Orthopedic surgery and Traumatology unit were analysed monthly by Hospital Safe Medication Use Committee from February 2022 to June 2023. Notifications were classified according to three factors: causality (prescription, administration, reconciliation, monitoring, transfers, labeling, dispensing, similarity of packaging and/or name), severity (potential circumstance to produce ME, incident that does not reach the patient, incident without harm and adverse events) and notifying personnel (physicians, nurses or pharmacists). Contributing factors were also identified and improvement actions were proposed.

Results A total of 83 ME voluntary reports were analysed. 74.6% of them were prescription errors, 6% were related to administration and 4.8% were related to reconciliation and monitoring. In terms of severity, 47.8% were harmless incidents, 26.5% were potential ME-causing circumstances, 19.3% were incidents that did not reach the patient and 7.2% were adverse events that did cause harm. The reporting personnel were mostly nurses (58%) and pharmacists (25%). The main contributing factors identified were daily review electronic prescriptions failure, lack of reconciliation of the patient‘s regular medication and variability in paediatric patient prescriptions. Improvement actions implemented were a specific protocol for the management of paediatric trauma patients, a multidisciplinary study of prescription errors and an informative session in the Orthopaedic surgery and traumatology unit where we explain the reported ME and specific recommendations were given to avoid them.

Conclusion and Relevance The analysis of the reported ME has allowed us to identify the contributing factors and to establish recommendations to modify them. Further studies of prescription errors will allow us to monitor the impact of the implemented actions.

Conflict of Interest No conflict of interest.

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