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Medication administration errors and mortality: Incidents reported in England and Wales between 2007 ̶ 2016

Research output: Contribution to journalArticle

Marja Härkänen, Katri Vehviläinen-Julkunen, Trevor Murrells, Anne Marie Rafferty, Bryony Dean Franklin

Original languageEnglish
JournalResearch In Social & Administrative Pharmacy
Early online date22 Nov 2018
DOIs
Publication statusE-pub ahead of print - 22 Nov 2018

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Abstract

Background Medication administration errors may contribute to patient mortality, thus additional understanding of such incidents is required. Objectives To analyse medication administration errors reported in acute care as resulting in death, to identify the drugs concerned, and to describe medication administration error characteristics (location of error, error type, patient's age) by drug group. Methods Medication administration errors reported in acute care in 2007 ̶ 2016 (n = 517,384) were obtained from the National Reporting and Learning System for England and Wales. Incidents reported as resulting in death (n = 229) were analysed. Drugs were classified by two researchers using the British National Formulary. Drug categories were described by medication administration errors' year, location, patient age, and error category based on the incidents’ original classification. Results Errors were most often reported on wards (66.4%, n = 152), and in patients aged over 75 years (41.5%, n = 95). The most common error category was omitted medicine or ingredient (31.4%, n = 72); most common drug groups were cardiovascular (20.1%, n = 46) and nervous system (10.0%, n = 23). Most errors in patients under 12 years concerned drugs to treat infection; cardiovascular drugs were most common among other age groups. Conclusions In order to prevent these most serious of medication administration errors, interventions should focus on avoiding dose omissions, and administration of drugs for patient over 75 years old, as well as safe administration of parenteral anticoagulants and antibacterial drugs.

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