Retrospective review of medication-related incidents at a major teaching hospital and the potential mitigation of these incidents with electronic prescribing and medicines administration

Cattell, Millie; Hyde, Kira; Bell, Brian; Dawson, Thomas; Hills, Tim; Iyen, Barbara; Khimji, Adam; Avery, Anthony

Abstract

Objectives To describe the frequency of the different types of medication-related incidents that caused patient harm, or adverse consequences, in a major teaching hospital and investigate whether the likelihood of these incidents occurring would have been reduced by electronic prescribing and medicines administration (EPMA).

Methods A retrospective review of harmful incidents (n=387) was completed for medication-related reports at the hospital between 1 September 2020 and 31 August 2021. Frequencies of different types of incidents were collated. The potential for EPMA to have prevented these incidents was assessed by reviewing DATIX reports and additional information, including results of any investigations.

Results The largest proportion of harmful medication incidents were administration related (n=215, 55.6%), followed by incidents classified as ’other’ and ’prescribing’. Most incidents were classified as low harm (n=321, 83.0%). EPMA could have reduced the likelihood of all incidents which caused harm by 18.6% (n=72) without configuration, and a further 7.5% (n=29) with configuration where configuration refers to adapting the software’s functionality without supplier input or development. For 18.4% of the low-harm incidents (n=59) and 20.3% (n=13) of the moderateharm incidents, EPMA could reduce the likelihood of the incident occurring without configuration. Medication errors most likely to be reduced by EPMA were due to illegibility, multiple drug charts or missing drug charts.

Conclusion This study found that administration incidents were the most common type of medicationrelated incidents. Most of the incidents (n=243, 62.8%) could not be mitigated by EPMA in any circumstance, even with connectivity between technologies. EPMA has the potential to prevent certain types of harmful medication related incidents, and further improvements could be achieved with configuration and development.

Citation

Cattell, M., Hyde, K., Bell, B., Dawson, T., Hills, T., Iyen, B., …Avery, A. (2023). Retrospective review of medication-related incidents at a major teaching hospital and the potential mitigation of these incidents with electronic prescribing and medicines administration. European Journal of Hospital Pharmacy, https://doi.org/10.1136/ejhpharm-2022-003515

• Journal Article Type: Article
• Acceptance Date: Feb 6, 2023
• Online Publication Date: Mar 3, 2023
• Publication Date: Mar 3, 2023
• Deposit Date: Mar 7, 2023
• Publicly Available Date: Mar 7, 2023
• Print ISSN: 2047-9956
• Electronic ISSN: 2047-9964
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• DOI: https://doi.org/10.1136/ejhpharm-2022-003515
• Public URL: https://nottingham-repository.worktribe.com/output/18227298
• Publisher URL: https://ejhp.bmj.com/content/early/2023/03/02/ejhpharm-2022-003515