TY - JOUR
T1 - Factors related to medication administration incidents in england and wales between 2007 and 2016
T2 - A retrospective trend analysis
AU - Härkänen, Marja
AU - Vehviläinen-Julkunen, Katri
AU - Franklin, Bryony Dean
AU - Murrells, Trevor
AU - Rafferty, Anne Marie
N1 - Funding Information:
This work was financially supported by postdoctoral research funding for M.H. by the Academy of Finland. B.D.F. is supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre, and the NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London, in partnership with Public Health England (PHE). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, PHE, or the Department of Health and Social Care.
Funding Information:
B.D.F. supervises a PhD student part funded by Cerner, a supplier of hospital electronic health record systems, and has received funding from Pfizer for delivering teaching at a one-off symposium on medication safety unrelated to this study.
Publisher Copyright:
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
PY - 2021/12/1
Y1 - 2021/12/1
N2 - Objectives: The aims of the study were to describe medication administration incidents reported in England and Wales between 2007 and 2016, to identify which factors (reporting year, type of incident, patients’ age) are most strongly related to reported severity of medication administration incidents, and to assess the extent to which relevant information was underreported or indeterminate. Methods: Medication administration incidents reported to the National Reporting & Learning System between January 1, 2007, and December 31, 2016 were obtained. Characteristics of the data were described using frequencies, and relationships between variables were explored using cross-tabulation. Results: A total of 517,384 incident reports were analyzed. Of these, 97.1% (n = 502,379) occurred in acute/general hospitals, mostly on wards (69.1%, n = 357,463), with medicine the most common specialty area (44.5%, n = 230,205). Medication errors were most commonly omitted doses (25.8%, n = 133,397). The majority did not cause patient harm (83.5%, n = 432,097). When only incidents causing severe harm or death (n = 1,116) were analyzed, the most common type of error was omitted doses (24.1%). Most incidents causing severe harm or death occurred in patients aged 56 years or older. For the 10-year period, the percentage of incidents with “no harm” increased (74.1% in 2007 to 86.3% in 2016). For some variables, data were often missing or indeterminate, which has implications for data analysis. Conclusions: Medication administration incidents that do not cause harm are increasingly reported, whereas incidents reported as severe harm and death have declined. Data quality needs to be improved. Underreporting and indeterminate data, inaccuracies in reporting, and coding jeopardize the overall usefulness of these data.
AB - Objectives: The aims of the study were to describe medication administration incidents reported in England and Wales between 2007 and 2016, to identify which factors (reporting year, type of incident, patients’ age) are most strongly related to reported severity of medication administration incidents, and to assess the extent to which relevant information was underreported or indeterminate. Methods: Medication administration incidents reported to the National Reporting & Learning System between January 1, 2007, and December 31, 2016 were obtained. Characteristics of the data were described using frequencies, and relationships between variables were explored using cross-tabulation. Results: A total of 517,384 incident reports were analyzed. Of these, 97.1% (n = 502,379) occurred in acute/general hospitals, mostly on wards (69.1%, n = 357,463), with medicine the most common specialty area (44.5%, n = 230,205). Medication errors were most commonly omitted doses (25.8%, n = 133,397). The majority did not cause patient harm (83.5%, n = 432,097). When only incidents causing severe harm or death (n = 1,116) were analyzed, the most common type of error was omitted doses (24.1%). Most incidents causing severe harm or death occurred in patients aged 56 years or older. For the 10-year period, the percentage of incidents with “no harm” increased (74.1% in 2007 to 86.3% in 2016). For some variables, data were often missing or indeterminate, which has implications for data analysis. Conclusions: Medication administration incidents that do not cause harm are increasingly reported, whereas incidents reported as severe harm and death have declined. Data quality needs to be improved. Underreporting and indeterminate data, inaccuracies in reporting, and coding jeopardize the overall usefulness of these data.
KW - England
KW - Hospital
KW - Incident reporting
KW - Medication administration error
KW - Medication error
KW - NRLS
KW - Patient safety
KW - Wales
UR - http://www.scopus.com/inward/record.url?scp=85092481683&partnerID=8YFLogxK
U2 - 10.1097/PTS.0000000000000639
DO - 10.1097/PTS.0000000000000639
M3 - Article
AN - SCOPUS:85092481683
SN - 1549-8417
VL - 17
SP - E850-E857
JO - Journal of patient safety
JF - Journal of patient safety
IS - 8
ER -
