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CP-007 Medication errors in voluntary reported incidents at a university hospital

Background A significant yet preventable cause of inpatient and outpatient morbidity and mortality is medication errors. Appropriate error reporting systems are the cornerstone of any plan designed to enhance patient safety.1 Purpose The aim of the study was to assess the prevalence, origin, type and severity of reported medication incidents at a university hospital, utilising a voluntary non-punitive reporting system. Material and methods The present study had a retrospective design. All voluntary non-punitive incident reports that occurred between January 2014 and March 2015 at the hospital were retrieved from the quality department. Detailed content analysis was conducted to obtain all relevant information. Data were coded anonymously and analysed using SPSS version 20. Results There was an increase in reporting of medication errors over time, and almost all of the reports were from nurses. A total of 58 medication error reports, involving 86 medications, were related to errors in the medication management process, from prescribing and dispensing to administration of medications. Two-thirds of the reports originated from the internal medicine department and the neonatal intensive care unit. The most common drug classes associated with these reports were anti-infectives, cardiovascular and chemotherapy agents. The majority of errors occurred during the administration phase where missed doses and wrong time accounted for more than 52% of the reported incidents. Approximately 98.8% of reported incidents did not cause major harm to patients. Conclusion A low number of medication errors were reported in multiple hospital departments that increased over time, utilising a non-punitive system of reporting, suggesting an initial success of the system. Additional research is required to identify possible improvements to optimise and encourage reporting in addition to enhancing the response to each report. References and/or acknowledgements 1. Cohen MR. Why error reporting systems should be voluntary. BMJ2000;320:728–9. Conflict of interest Corporate sponsored research or other substantive relationships: Dr Khawla Abu Hamour is the head of the pharmaceutical unit at the hospital.