Skip to main content
×
×
Home

A medication error reporting scheme: analysis of the first 12 months

  • Ian D. Maidment (a1) and Angie Thorn (a2)
Abstract
Aims and Method

A new medication error reporting scheme (‘Safemed’) was introduced within the East Kent NHS and Social Care Partnership Trust. All medication incidents reported using this system in the first year were analysed by the Chief Pharmacist.

Results

Over a 12-month period a total of 66 incidents were reported through Safemed, compared with 55 incidents under the previous system. The low level of reporting made detailed statistical analysis and drawing meaningful conclusions problematic. There was a large variability in reporting between similar sites.

Clinical Implications

The low level of reporting was associated with cultural factors, in particular the failure to fully implement a ‘no blame’ culture. Until such a culture is established, reporting will remain variable and a systems approach to preventing medication errors will not be adopted, leading to significant clinical risk.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      A medication error reporting scheme: analysis of the first 12 months
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      A medication error reporting scheme: analysis of the first 12 months
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      A medication error reporting scheme: analysis of the first 12 months
      Available formats
      ×
Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
Hide All
ANON (2003) Pharmacists have major role in national initiative on patient risk, Council hears. Pharmaceutical Journal, 271, 249250.
Bates, D.W., Leape, L. L. & Petrycki, S. (1993) Incidence and preventability of adverse drug events in hospitalised adults. Journal of General Internal Medicine, 8, 289294.
Bates, D. W., Cullen, D. J., Laird, N., et al (1995) Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA, 274, 2934.
Bumpus, L. & Al-Assaf, A. F. (2003) Using performance improvement strategies to reduce and prevent medication errors. 1. Journal of Cardiovascular Management, 14, 1518.
Dean, B. & Barber, N. (2001) Validity and reliability of observational methods for studying medication administration errors. American Journal of Health System Pharmacy, 58, 5459.
Dean, B., Schachter, M., Vincent, C., et al (2002) Causes of prescribing errors in hospital inpatients: a prospective study. Lancet, 359, 13731378.
Department of Health (2000) An Organisation With a Memory. Report of an Expert Group on Learning from Adverse Events in the NHS. London: Stationery Office.
Department of Heatlh (2001) Building a Safer NHS for Patients. London: Stationery Office.
Department of Health (2003) Building a Safer NHS for Patients – Improving Patient Safety. London: Stationery Office.
Dodds, L. & Leaver, S. (2003) An integrated medication risk management system for East Kent. Pharmaceutical Journal, 270, 450453.
France, D. J., Miles, P., Cartwright, J., et al (2003) A chemotherapy incident reporting and improvement system. Joint Commission Journal on Quality and Safety, 29, 171180.
Furukawa, H., Bunko, H., Tsuchiya, F., et al (2003) Voluntary medication error reporting program in a Japanese national university hospital. Annals of Pharmacotherapy, 37, 17161722.
Grasso, B. C., Genest, R., Jordan, C.W., et al (2003) Use of chart and record reviews to detect medication errors in a state psychiatric hospital. Psychiatric Services, 54, 677681.
Hannagan, T. (2002) Management – Concepts and Practices (3rd edn). Harlow: Pearson.
Hatch, M. J. (1997) Organizational Theory – Modern Symbolic and Postmodern Perspectives. Oxford: Oxford University Press.
Howard, R. L., Avery, A. J., Howard, P. D., et al (2003) Investigation into the reasons for preventable drug related admissions to a medical admissions unit: observational study. Quality and Safety in Health Care, 12, 280285.
Ito, H. & Yamazumi, S. (2003) Common types of medication errors on long-term psychiatric care units. International Journal for Quality in Health Care, 15, 207212.
Koren, G. (2002) Trends of medication errors in hospitalised children. Journal of Clinical Pharmacology, 42, 707710.
Leape, L. L. (1994) Error in medicine. JAMA, 272, 18511857.
Lelliott, P. (2004) The National Patient Safety Agency. Psychiatric Bulletin, 28, 193195.
Smith, L. (2003) Developing a medication incident reporting scheme. Hospital Pharmacy Europe, 9, 3941.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 3 *
Loading metrics...

Abstract views

Total abstract views: 23 *
Loading metrics...

* Views captured on Cambridge Core between 2nd January 2018 - 27th April 2018. This data will be updated every 24 hours.

A medication error reporting scheme: analysis of the first 12 months

  • Ian D. Maidment (a1) and Angie Thorn (a2)
Submit a response

eLetters

No eLetters have been published for this article.

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *