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Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors
INTRODUCTION: Prescribing errors are a principal cause of preventable harm in healthcare. This study aims to establish a systematic approach to analysing prescribing-related adverse incident reports, in order to elucidate the characteristics and contributing factors of common prescribing errors and...
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
BMJ Publishing Group
2020
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326251/ https://www.ncbi.nlm.nih.gov/pubmed/32601176 http://dx.doi.org/10.1136/bmjoq-2020-000949 |
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author | Lane, Natalie Hunter, Ian |
author_facet | Lane, Natalie Hunter, Ian |
author_sort | Lane, Natalie |
collection | PubMed |
description | INTRODUCTION: Prescribing errors are a principal cause of preventable harm in healthcare. This study aims to establish a systematic approach to analysing prescribing-related adverse incident reports, in order to elucidate the characteristics and contributing factors of common prescribing errors and target multifaceted quality improvement initiatives. METHODS: All prescribing-related adverse incident reports submitted across one NHS board over 12 months were selected. Incidents involving commonly implicated drugs (involved in ≥10 incidents) underwent analysis to establish likely underlying causes using Reason’s Model of Accident Causation. RESULTS: 330 prescribing-related adverse incident reports were identified. Commonly implicated drugs were insulin (10% of incidents), gentamicin (7%), co-amoxiclav (5%) and amoxicillin (5%). The most prevalent error types were prescribing amoxicillin when contraindicated due to allergy (5%); prescribing co-amoxiclav when contraindicated due to allergy (5%); prescribing the incorrect type of insulin (3%); and omitting to prescribe insulin (3%). Error-producing factors were identified in 86% of incidents involving commonly implicated drugs. 53% of incidents involved error-producing factors related to the working environment; 38% involved factors related to the healthcare team; and 37% involved factors related to the prescriber. DISCUSSION: This study establishes that systematic analysis of adverse incident reports can efficiently identify the characteristics and contributing factors of common prescribing errors, in a manner useful for targeting quality improvement. Furthermore, this study produced a number of salient findings. First, a narrow range of drugs were implicated in the majority of incidents. Second, a small number of error types were highly recurrent. Lastly, a range of contributing factors were evident, with those related to the working environment contributing to the majority of prescribing errors analysed. |
format | Online Article Text |
id | pubmed-7326251 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2020 |
publisher | BMJ Publishing Group |
record_format | MEDLINE/PubMed |
spelling | pubmed-73262512020-07-02 Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors Lane, Natalie Hunter, Ian BMJ Open Qual Short Report INTRODUCTION: Prescribing errors are a principal cause of preventable harm in healthcare. This study aims to establish a systematic approach to analysing prescribing-related adverse incident reports, in order to elucidate the characteristics and contributing factors of common prescribing errors and target multifaceted quality improvement initiatives. METHODS: All prescribing-related adverse incident reports submitted across one NHS board over 12 months were selected. Incidents involving commonly implicated drugs (involved in ≥10 incidents) underwent analysis to establish likely underlying causes using Reason’s Model of Accident Causation. RESULTS: 330 prescribing-related adverse incident reports were identified. Commonly implicated drugs were insulin (10% of incidents), gentamicin (7%), co-amoxiclav (5%) and amoxicillin (5%). The most prevalent error types were prescribing amoxicillin when contraindicated due to allergy (5%); prescribing co-amoxiclav when contraindicated due to allergy (5%); prescribing the incorrect type of insulin (3%); and omitting to prescribe insulin (3%). Error-producing factors were identified in 86% of incidents involving commonly implicated drugs. 53% of incidents involved error-producing factors related to the working environment; 38% involved factors related to the healthcare team; and 37% involved factors related to the prescriber. DISCUSSION: This study establishes that systematic analysis of adverse incident reports can efficiently identify the characteristics and contributing factors of common prescribing errors, in a manner useful for targeting quality improvement. Furthermore, this study produced a number of salient findings. First, a narrow range of drugs were implicated in the majority of incidents. Second, a small number of error types were highly recurrent. Lastly, a range of contributing factors were evident, with those related to the working environment contributing to the majority of prescribing errors analysed. BMJ Publishing Group 2020-06-29 /pmc/articles/PMC7326251/ /pubmed/32601176 http://dx.doi.org/10.1136/bmjoq-2020-000949 Text en © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. |
spellingShingle | Short Report Lane, Natalie Hunter, Ian Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors |
title | Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors |
title_full | Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors |
title_fullStr | Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors |
title_full_unstemmed | Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors |
title_short | Lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors |
title_sort | lessons learned: using adverse incident reports to investigate the characteristics and causes of prescribing errors |
topic | Short Report |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326251/ https://www.ncbi.nlm.nih.gov/pubmed/32601176 http://dx.doi.org/10.1136/bmjoq-2020-000949 |
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