RESUMEN
Background: Medication-related safety incidents (MSIs) are among the most frequent contributors to preventable harm in hospital patients. There is a paucity of research that explores the factors that contribute to MSIs across the departments of high-risk specialties such as surgery. Objectives: To characterize MSIs involving surgical patients across two secondary care sites at a University Health Board. Design: Retrospective cross-sectional convergent analysis of anonymous MSI reports extracted from the risk management system between 1st January 2017 and 31st October 2020 was undertaken. Methods: Incident reports contained categorical data pertaining to the type and nature of the incident as well as free-text reporter accounts. Categorical data were analyzed quantitatively, undergoing descriptive analysis using IBM SPSS Statistics © software (Version 26.0.01; 2019). Content analysis of free-text responses was undertaken using the Organizational Accident Causation model as the underpinning theoretical framework. Results: Of a total of 670 incidents, most MSIs did not result in harm (n = 495, 73.9%). Most MSIs occurred during administration (n = 439, 65.5%). Half of the incidents (n = 335, 50%) were related to one of three medication types: opioids, antimicrobials, and antithrombotic agents. Communication failures were the most frequent error-producing condition (n = 39, 5.8%) and drug omission was the most frequent active failure (n = 156, 23.3%). Conclusion: To the knowledge of the authors, this is the first study in the United Kingdom that reports the medications most frequently involved in MSI reports for surgical patients. Staff in the surgical setting should be informed of the high frequency of incidents involving opioids, antimicrobials, heparin, and other antithrombotic agents as they appear in half of MSI reports in the surgical setting. Further research should explore administration error reduction strategies as well as tools to improve communication between staff to mitigate the risk of medicines-related harm associated with key medications.
Introduction: Errors with medications not only often happen in hospitals but also have the potential to cause great harm to patients. They can occur at any time, from prescribing a patient the correct dose of medication to finally administering them the correct medication. Reducing the risk of errors is particularly crucial for surgical patients, where medication-related safety incidents can complicate the safety of surgical procedures. This study looked at the types of medication incidents reported by staff for patients who were having surgery. Methods: We reviewed the incident reports involving medications for patients on surgical wards and in theatres, as reported by staff. These included reports from between 1st January 2017 and 31st October 2020 from two university hospitals in Wales. Results: A total of 670 incidents were reported by staff, most of which did not result in any harm (n = 495, 73.9%). Half of the incidents that were reported involved at least one of three types of medications: opioids, antimicrobials and blood thinning medication. Communication failures were attributed to be the most common factor leading to errors occurring, whilst a failure to give the medication was the most common error reported. Conclusion: Staff that are working with patients on surgical wards and in theatres should be alerted to the high frequency of incidents involving opioids, antimicrobials and blood thinning medication. Moreover, strategies that improve staff communication should be employed to avoid medication-related safety incidents.
Types of medicines-related errors occurring in patients undergoing surgery.
RESUMEN
OBJECTIVES: To determine the common stages and strategies involved in the dispensing accuracy-checking process used by pharmacy staff and to determine the training activities used by these staff to gain the knowledge and skills for accuracy checking. METHOD: Face-to-face tape-recorded ethnographic interviews (n = 28) were undertaken in 2009-2010 at two large teaching hospitals with a purposive sample of pharmacists and accredited checking technicians qualified to undertake the final accuracy check on dispensed medicines. Participants described their accuracy-checking process, strategies used to aid checking using anonymised prescriptions and accurate dispensing of medicines to aid discussion. The range of training activities undertaken to develop this skill were discussed. Qualitative data were analysed in accordance with the principles of grounded theory to identify themes. KEY FINDINGS: The accuracy-checking process was described as a cognitive and systematic process. The order in which accuracy checking was executed was found to follow two pathways, with all participants checking the prescription first before verifying either the label or dispensed product. Various physical and sensory aids were used to assist in this verification process. There were inconsistencies in the level of accuracy-checking training received by pharmacists and accredited checking technicians, with many pharmacists reporting no training. CONCLUSION: Although an important medication-error prevention strategy, until this study little was known about the process used by pharmacy staff when verifying the accuracy of dispensed medicines. Accuracy checking is a complex cognitive task involving verification of the product and label with the prescription. Strategies obtained during past experience and in training were used to aid checking. The study highlighted that pharmacy staff training to undertake this task was variable. Application of strategies identified in this study may allow individuals to adopt further safeguards to improve patient safety.