Medication mishaps are the most common errors in healthcare. Indeed, medication errors represent the most frequently reported events submitted to ECRI Institute Patient Safety Organization (PSO)—comprising about 30% of all events. To assist healthcare facilities in learning from medication errors, ECRI Institute PSO developed and conducted a deep dive analysis on medication safety, uncovering a number of important process issues within hospitals.
As part of the deep dive, ECRI Institute PSO asked participating organizations to submit medication events over a 5-week period so that ECRI Institute PSO could identify patterns and trends from the aggregated data and share its findings and recommendations.
Although errors can occur during any stage of the medication process, ECRI Institute PSO facilities indicated that most events specific to one stage occurred during administration of the medication (see Figure). Of the 320 reports for administration-only errors, intravenous (IV)-related errors were the most frequently occurring events, representing 36.9% of administration-only events.
“While the deep dive represents only a snapshot of medication errors, we found administration errors to be the highest. It was interesting to see that the type of errors varied based on the modality of administration,” says Karen P. Zimmer, MD, MPH, FAAP, medical director, ECRI Institute PSO. “To be effective in reducing administration errors, we must harness a combination of techniques that will address the various error types.”
ECRI Institute PSO recommended strategies for the safety of medication administration, particularly with IV infusions. To prevent medication errors, it is important to identify system-based causes of these errors rather than the current tendency to focus on human performance.
The findings were reported in a 28-page report, webinar, and Medication Safety Toolkit, which are available to all ECRI Institute PSO members. Summary information about these findings was also presented in the May edition of the PSO Monthly Brief, a free eNewsletter comprised of a brief article each month to help keep readers informed about Patient Safety Organizations. To sign up for the PSO Monthly Brief, go to www.ecri.org/psobrief.
ECRI Institute PSO has already begun collecting data for its next deep dive on health information technology (HIT).
About ECRI Institute
For nearly 45 years, ECRI Institute’s work in patient safety, adverse event reporting and analysis, and development of recommendations has improved patient care at hospitals and other providers around the world. ECRI Institute Patient Safety Organization is a component of ECRI Institute, a nonprofit 501(c)(3) organization dedicated to improving the safety, quality, and cost-effectiveness of patient care. ECRI Institute has a long history of investigating events and publishing authoritative risk reduction strategies. ECRI Institute is designated as an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. ECRI Institute developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other healthcare facilities, under contract to the Pennsylvania Patient Safety Authority, winner of the 2006 John M. Eisenberg Award. For more information, visit www.ecri.org. Find ECRI Institute on Facebook (www.facebook.com/ECRIInstitute) and Twitter (www.twitter.com/ECRI_Institute).