Abstract
Background
Medication safety incidents commonly occur in mental health hospitals. There is a need to improve understanding of the circumstances, actions or influences which are thought to have played a part in the origin of these medication incidents in order to design safer systems to improve patient safety.
Aim
To undertake a mixed-methods analysis of medication safety incidents reported to the National Reporting and Learning System (NRLS) in England and Wales during 2010-2017.
Method
Descriptive analyses were undertaken of all anonymised medication safety incidents reported to the NRLS over an eight-year period to characterise their type, severity, and the medication(s) involved. Secondly, a thematic analysis of the free-text reports for incidents reported with moderate or more serious outcomes was undertaken to identify the underlying contributory factors.
Result
In total, 93,727 medication incident reports were identified and 10.4% (n=9,755) described harmful outcomes. Administration errors accounted for the majority of medication incidents reported (50,314; 53.6%), followed by prescribing (15,480; 16.5%) and dispensing errors (10,871; 11.6%). Omission of medication (17,210; 18.3%), wrong frequency (11,860; 12.6%) and wrong/unclear dose of medication (10,251; 10.9%) were most frequently reported. The most frequent drug classes involved were antipsychotics (14,934; 15.5%) and anxiolytics/hypnotics (8,129; 8.4%) and antidepressants (5,776; 6.0%). Failure to follow protocols (n=93), lack of continuity of care (n=92), patient behaviours (n=62) and lack of stock (n=51) were frequently reported as contributory factors associated with moderate, severe and death outcomes.
Conclusion
Medication incidents pose an enduring threat to patient safety in mental health hospitals. This study has identified important targets which can guide the development of remedial interventions that are tailored to the mental health inpatient setting.
Medication safety incidents commonly occur in mental health hospitals. There is a need to improve understanding of the circumstances, actions or influences which are thought to have played a part in the origin of these medication incidents in order to design safer systems to improve patient safety.
Aim
To undertake a mixed-methods analysis of medication safety incidents reported to the National Reporting and Learning System (NRLS) in England and Wales during 2010-2017.
Method
Descriptive analyses were undertaken of all anonymised medication safety incidents reported to the NRLS over an eight-year period to characterise their type, severity, and the medication(s) involved. Secondly, a thematic analysis of the free-text reports for incidents reported with moderate or more serious outcomes was undertaken to identify the underlying contributory factors.
Result
In total, 93,727 medication incident reports were identified and 10.4% (n=9,755) described harmful outcomes. Administration errors accounted for the majority of medication incidents reported (50,314; 53.6%), followed by prescribing (15,480; 16.5%) and dispensing errors (10,871; 11.6%). Omission of medication (17,210; 18.3%), wrong frequency (11,860; 12.6%) and wrong/unclear dose of medication (10,251; 10.9%) were most frequently reported. The most frequent drug classes involved were antipsychotics (14,934; 15.5%) and anxiolytics/hypnotics (8,129; 8.4%) and antidepressants (5,776; 6.0%). Failure to follow protocols (n=93), lack of continuity of care (n=92), patient behaviours (n=62) and lack of stock (n=51) were frequently reported as contributory factors associated with moderate, severe and death outcomes.
Conclusion
Medication incidents pose an enduring threat to patient safety in mental health hospitals. This study has identified important targets which can guide the development of remedial interventions that are tailored to the mental health inpatient setting.
| Original language | English |
|---|---|
| Journal | Journal of Patient Safety |
| Publication status | Accepted/In press - 20 Aug 2020 |