Medication errors management process in hospital: a 6-month pilot study.
Fundam Clin Pharmacol. 2011 Dec;25(6):768-75
Authors: Thomas L, Cordonnier-Jourdin C, Benhamou-Jantelet G, Diviné C, Le Louët H
The objectives of this study are to assess the relevance of the medication error reporting system in a French teaching hospital, to enable the collection of medication error reports and to take corrective actions to reduce occurrence. This is a prospective pilot study based on blame-free reporting by healthcare professionals. The study setting is five medical/surgical departments in a French teaching hospital over a 6-month period. The main outcomes of this study are types, frequency, and consequences of medication errors reported. Over a 6-month period, 47 medication errors were reported. Twenty-eight (60%) were related to the prescription process, of which 17 were prescribing errors, 10 were because of data capture error and one was because of software malfunction. Ten medication errors (21%) were related to the dispensing process and eight (17%) to errors occurring during drug administration. Finally, one medication error (2%) was related to prescription, dispensing, and administration. The reporting process was accepted by most healthcare professionals who agreed to initiate medication errors reports upon assurance that data collection will be confidential. The reporting process led to several avoidance actions to minimize the medication error risk. Maintaining confidentiality embedded within a nonpunitive environment, this method was accepted by all participating personnel. Medication errors could be collected, reviewed, and corrective actions taken. This strategy can be a first step in a long-term ongoing process to prevent future medication errors in hospitals.
PMID: 21210845 [PubMed - indexed for MEDLINE]