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Severe and fatal medication errors in hospitals: findings from the Norwegian Incident Reporting System
  1. Alma Mulac1,
  2. Katja Taxis2,
  3. Ellen Hagesaether3,
  4. Anne Gerd Granas1
  1. 1Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
  2. 2Unit of Pharmacotherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, The Netherlands
  3. 3Department of Life Sciences and Health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
  1. Correspondence to Alma Mulac, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo 0316, Norway; alma.mulac{at}farmasi.uio.no

Abstract

Background Even with global efforts to prevent medication errors, they still occur and cause patient harm. Little systematic research has been done in Norway to address this issue.

Objectives To describe the frequency, stage and types of medication errors in Norwegian hospitals, with emphasis on the most severe and fatal medication errors.

Methods Medication errors reported in 2016 and 2017 (n=3557) were obtained from the Norwegian Incident Reporting System, based on reports from 64 hospitals in 2016 and 55 in 2017. Reports contained categorical data (eg, patient age, incident date) and free text data describing the incident. The errors were classified by error type, stage in the medication process, therapeutic area and degree of harm, using a modified version of the WHO Conceptual Framework for the International Classification for Patient Safety.

Results Overall, 3372 reports were included in the study. Most medication errors occurred during administration (68%) and prescribing (24%). The leading types of errors were dosing errors (38%), omissions (23%) and wrong drug (15%). The therapeutic areas most commonly involved were analgesics, antibacterials and antithrombotics. Over half of all errors were harmful (62%), of which 5.2% caused severe harm, and 0.8% were fatal.

Conclusions Medication errors most commonly occurred during medication administration. Dosing errors were the most common error type. The substantial number of severe and fatal errors causing preventable patient harm and death emphasises an urgent need for error-prevention strategies. Additional studies and interventions should further investigate the error-prone medication administration stage in hospitals and explore the dynamics of severe incidents.

  • clinical pharmacy
  • organisation of health services
  • risk management
  • medication errors
  • quality management
  • medication safety
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