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Wrong‐patient incidents during medication administrations

AIMS AND OBJECTIVES
To describe the factors pertaining to medication being administered to the wrong patient and to describe how patient identification is mentioned in wrong-patient incident reports.


BACKGROUND
Although patient identification has been given high priority to improve patient safety, patient misidentifications occur, and wrong-patient incidents are common.


DESIGN
A descriptive content analysis.


METHODS
Incident reports related to medication administration (n = 1,012) were collected from two hospitals in Finland between 1 January 2013-31 December 2014. Of those, only incidents involving wrong-patient medication administration (n = 103) were included in this study.


RESULTS
Wrong-patient incidents occurred due for many reasons, including nurse-related factors (such as tiredness, a lack of skills or negligence) but also system-related factors (such as rushing or heavy workloads). In 77% (n = 79) of wrong-patient incident reports, the process of identifying of the patient was not described at all.


CONCLUSIONS
There is need to pay more attention to and increase training in correct identification processes to prevent wrong-patient incidents, and it is important to adjust system factors to support nurses.


RELEVANCE TO CLINICAL PRACTICE
Active patient identification procedures, double-checking and verification at each stage of the medication process should be implemented. More attention should also be paid to organisational factors, such as division of work, rushing and workload, as well as to correct communication. The active participation of nurses in handling incidents could increase risk awareness and facilitate useful protection actions.