Incidence of medication errors in the drug administration system in the More d’Ebre Regional Hospital in Tarragona
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Bordera Bigorra M, Pàez Vives F, Pros Poquet R, Isach Vàzquez S, Montaña Raduà R, Adell Vidal N. Incidencia de los errores de medicación en los procesos del sistema de utilización de medicamentos. Metas de Enferm oct 2008; 11(8): 50-55
Authors
1Marta Bordera Bigorra, 2Francesc Pàez Vives, 1Rita Pros Poquet, 1Sílvia Isach Vàzquez, 3Rosa Montaña Raduà
Position
1Enfermera de hospitalización. Hospital Comarcal Móra d’Ebre (Tarragona).2Farmacéutico hospitalario. Hospital Comarcal Mora d'Ebre.3Técnica de Farmacia en el Hospital Comarcal Móra d’Ebre.
Contact address
Servicio de Farmacia Hospital Comarcal Móra d’Ebre. C/ Benet Messeguer, s/n. 43740 Móra d’Ebre (Tarragona).
Contact email: fpaez@grupsagessa.cat
Abstract
Objectives: to determine the global rate of medication errors in the process of drug utilisation, as well as the types of errors made, their seriousness, consequences and the percentage of patients affected in the Móra d’Ebre Regional Hospital (HCME acronym in Spanish).
Material and method: longitudinal descriptive study of acute patients admitted to the HCME between 25/06/2007 and 07/08/2007. It was estimated that a minimum of 1,500 administrations, distributed among the different shifts of the two units included in the study, were necessary for observation. The variables studied were “frequency of medication errors” (transcription, prescription, dispensing and administration), “seriousness” and “consequences” in the patient. Accumulated Incidence was used to determine the incidence.
Results: 17,551 drugs were dispensed. Four nurses monitored the 1,519 administrations to 479 patients. 97 errors were detected; 38,14% were administration errors, 30,93% were prescription errors, 17,53% were transcription errors and 1,03% were patient/treatment errors. The greatest number of errors (37,11%) was detected in the traumatology unit. In regards to seriousness, 56,70% were Category B. 22 of the errors were characterized by incorrect dose. Regarding causes, the most frequent cause was “lapse/forgetfulness” in 47 of the errors. The overall error rate was 0,55%. The global rate of affected patients was 18,65%.
Conclusions: administration errors are the most frequent, being those in which the nurse is most involved, followed by prescription errors. Forgetfulness or lapse along with the lack of a computerized medical prescription system account for 90% of the errors found. Nurses are the healthcare professionals who detect the greatest number of errors. Multidisciplinary strategies aimed at improving the safety of patients and decreasing the number of drug administration errors must be a priority in our everyday work.
Keywords:
medication errors; healthcare delivery quality; clinical safety; error rate; pharmacy; drugs; administration; prescription; validation; preparationdispensing
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