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5PSQ-042 Focus on medication errors on high-risk medications in a hospital’s electronic incident reporting system
  1. Y Andersson1,
  2. J Mezori2,
  3. SR Eikeland3,
  4. AG Granås2
  1. 1Hospital Pharmacies Enterprise- South-Eastern Norway, Hospital Pharmacies Enterprise, Oslo, Norway
  2. 2University of Oslo, Department of Pharmacy, Oslo, Norway
  3. 3Hospital Pharmacies Enterprise- South-Eastern Norway, Hospital Pharmacy Kalnes, Kalnes, Norway


Background and Importance High-risk medications, i.e. anticoagulants, digoxin, gentamicin, insulin, potassium, opioids and low-dose methotrexate, have an increased risk of causing patient harm when used incorrectly.

Barcode medication administration (BCMA) systems can reduce the risk of medication errors by focusing on the five R’s in medication management, i.e., the right patient, the right drug, the right dose, the right route, and the right time.

Aim and Objectives The aims were 1) to analyse and quantify medication errors in an electronic reporting system handling adverse events in a hospital with BMCA, and 2) to quantify the extent of high-risk medications that lacked a barcode at medicine unit level.

Material and Methods We analysed medication errors reported by hospital employees in the hospital’s electronic incident reporting system that handles adverse events. We have read and categorised the errors carefully in terms of type, frequency and where in drug handling the errors had occurred.

Results Hospital staff reported 1,777 medication errors and nearly 30% (n=467) were associated with high-risk medications. Most errors occurred during prescribing (n=133, 28%) and drug administration (n=189, 40%). Anticoagulants and opioids were most frequently reported. This also corresponds with that 14% (n=41) of the 293 different high-risk medication packages lacked barcodes at medicine unit level, most of which were anticoagulants and opioids.

Conclusion and Relevance Assigning a barcode to all high-risk medication packages, so high-risk medications can be scanned, can prevent future medication errors. Labelling barcodes at medicines unit level on anticoagulants and opioids should be prioritised.

Conflict of Interest No conflict of interest.

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