Analysis of the Nature and Contributory Factors of Medication Safety Incidents Following Hospital Discharge using National Reporting and Learning System (NRLS) Data from England and Wales: A Multi-Method Study

Introduction: Improving medication safety during transition of care is an international healthcare priority. Whilst existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy.
Aim: To characterise the nature and contributory factors of medication related incidents during transition of care from secondary to primary care.
Method: A retrospective analysis of medication incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019. Descriptive analysis identified the frequency and nature of incidents and content analysis of free text data, coded using the Patient Safety Research Group (PISA) classification, examined the contributory factors and outcome of incidents.
Results: A total of 1,121 medication-related incident reports underwent analysis. Most incidents involved patients over 65 years old (55%, n=626/1,121). More than one in ten (12.6%, n=142/1,121) incidents were associated with patient harm. The drug monitoring (17%) and administration stages (15%) were associated with a higher proportion of harmful incidents than any other drug use stages. Common medication classes associated with incidents were the cardiovascular (n=734) and central nervous (n=273) systems. Among 408 incidents reporting 467 contributory factors, the most common contributory factors were organisation factors (82%, n=383/467) (mostly related to continuity of care which is the delivery of a seamless service through integration, co-ordination, and the sharing of information between different providers), followed by staff factors (16%, n=75/467).
Conclusion: Medication incidents after hospital discharge are associated with patient harm. Several targets were identified for future research that could support the development of remedial interventions, including commonly observed medication classes, older adults, increase patient engagement, and improve shared care agreement for medication monitoring post hospital discharge.