Nikki How is currently a Resident Medical Officer at Fiona Stanley Hospital in Western Australia. She has a keen interest in improving medication safety in the hospital setting.
ACTION – A Retrospective Audit Of Medication Error
Aims: The aim of this audit is to assess the number and type of medication errors reported to Rockingham General Hospital over a one year period, and evaluate consequent complications or adverse events incurred by patients.
Methods: Retrospective data collection was completed from 1st January 2019 to 31st December 2019. Patients with medication-related incidents reported to a clinical incident management system were included in the study. Additional data was retrieved from patients’ medical records and discharge summaries. Data analysis was performed using SPSS v23 statistical package.
Results: We identified 188 patients with complete data that met the inclusion criteria, and all were included in the data analysis. More than 25% of patients involved in the study incurred harm from the medication errors made. There was an association with the type of error and the level of harm incurred by patients (Chi square p<0.0005), with most incidents attributed to errors with incorrect dose or incorrect medication. Anticoagulation errors resulted in most harm to patients. There was a significant difference between the type of medication and level of harm incurred (p<0.05). 13.8% of patients incurred side effects, 1.1% had an allergic/anaphylactic reaction, 0.5% had a fall, 1.6% had a code blue call, and 1.1% died as a possible consequence of the medication error. 4.8% of patients incurred extra days length of stay, ranging between an extra 1 to 7 days.
Conclusions: Overall, more than 25% of medication-related incidents reviewed in this study resulted in subsequent patient harm. The majority of incidents involved potentially preventable errors, predominantly from errors with incorrect dose or medication. We recommend consideration of an electronic medication management system to reduce the number of preventable errors. A focus should also be placed on strategies to reduce error-producing conditions, increasing education on medication errors and re-emphasising fundamentals of medication safety.