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What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?

OBJECTIVES: This study investigated severe medication errors (MEs) reported to the National Supervisory Authority for Welfare and Health (Valvira) in Finland and evaluated how the incident documentation applies to learning from errors. METHODS: This study was a retrospective document analysis consis...

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Autores principales: Linden-Lahti, Carita, Takala, Anna, Holmström, Anna-Riia, Airaksinen, Marja
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Lippincott Williams & Wilkins 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8612921/
https://www.ncbi.nlm.nih.gov/pubmed/34569999
http://dx.doi.org/10.1097/PTS.0000000000000914
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author Linden-Lahti, Carita
Takala, Anna
Holmström, Anna-Riia
Airaksinen, Marja
author_facet Linden-Lahti, Carita
Takala, Anna
Holmström, Anna-Riia
Airaksinen, Marja
author_sort Linden-Lahti, Carita
collection PubMed
description OBJECTIVES: This study investigated severe medication errors (MEs) reported to the National Supervisory Authority for Welfare and Health (Valvira) in Finland and evaluated how the incident documentation applies to learning from errors. METHODS: This study was a retrospective document analysis consisting of medication-related complaints and authoritative statements investigated by Valvira in 2013 to 2017 (n = 58). RESULTS: Medication errors caused death or severe harm in 52% (n = 30) of the cases (n = 58). The majority (83%; n = 48) of the incidents concerned patients older than 60 years. Most likely, the errors occurred in prescribing (n = 38; 47%), followed by administration (n = 15; 19%) and monitoring (n = 14; 17%). The error process often included many failures (n = 24; 41%) or more than one health professional (n = 16; 28%). Antithrombotic agents (n = 17; 13%), opioids (n = 10; 8%), and antipsychotics (n = 10; 8%) were the therapeutic groups most commonly involved in the errors. Almost all error cases (91%; n = 53) were assessed as likely or potentially preventable. In 60% (n = 35) of the cases, the organization reported actions taken to improve medication safety after the occurrence of the investigated incident. CONCLUSIONS: Medication errors reported to the national health care supervisory authority provide a valuable source of risk information and should be used for learning from severe errors at the level of health care systems. High age remains a key risk factor to severe MEs, which may be associated with a wide range of medications including those not typically perceived as high-alert medications or high-risk administration routes. Despite being complex processes, the severe MEs have a great potential to lead to developing systems, processes, resources, and competencies of health care organizations.
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spelling pubmed-86129212021-11-29 What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety? Linden-Lahti, Carita Takala, Anna Holmström, Anna-Riia Airaksinen, Marja J Patient Saf Original Studies OBJECTIVES: This study investigated severe medication errors (MEs) reported to the National Supervisory Authority for Welfare and Health (Valvira) in Finland and evaluated how the incident documentation applies to learning from errors. METHODS: This study was a retrospective document analysis consisting of medication-related complaints and authoritative statements investigated by Valvira in 2013 to 2017 (n = 58). RESULTS: Medication errors caused death or severe harm in 52% (n = 30) of the cases (n = 58). The majority (83%; n = 48) of the incidents concerned patients older than 60 years. Most likely, the errors occurred in prescribing (n = 38; 47%), followed by administration (n = 15; 19%) and monitoring (n = 14; 17%). The error process often included many failures (n = 24; 41%) or more than one health professional (n = 16; 28%). Antithrombotic agents (n = 17; 13%), opioids (n = 10; 8%), and antipsychotics (n = 10; 8%) were the therapeutic groups most commonly involved in the errors. Almost all error cases (91%; n = 53) were assessed as likely or potentially preventable. In 60% (n = 35) of the cases, the organization reported actions taken to improve medication safety after the occurrence of the investigated incident. CONCLUSIONS: Medication errors reported to the national health care supervisory authority provide a valuable source of risk information and should be used for learning from severe errors at the level of health care systems. High age remains a key risk factor to severe MEs, which may be associated with a wide range of medications including those not typically perceived as high-alert medications or high-risk administration routes. Despite being complex processes, the severe MEs have a great potential to lead to developing systems, processes, resources, and competencies of health care organizations. Lippincott Williams & Wilkins 2021-12 2021-09-27 /pmc/articles/PMC8612921/ /pubmed/34569999 http://dx.doi.org/10.1097/PTS.0000000000000914 Text en Copyright © 2017 The Author(s). Published by Wolters Kluwer Health, Inc. https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY) (https://creativecommons.org/licenses/by/4.0/) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Original Studies
Linden-Lahti, Carita
Takala, Anna
Holmström, Anna-Riia
Airaksinen, Marja
What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?
title What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?
title_full What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?
title_fullStr What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?
title_full_unstemmed What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?
title_short What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?
title_sort what severe medication errors reported to health care supervisory authority tell about medication safety?
topic Original Studies
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8612921/
https://www.ncbi.nlm.nih.gov/pubmed/34569999
http://dx.doi.org/10.1097/PTS.0000000000000914
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