• Elyssia M Bourke, Dawson Macleod, Jeff Robinson, and L GreeneShaunSVictorian Poisons Information Centre, Austin Health, Melbourne, Victoria, Australia..
• Victorian Poisons Information Centre, Austin Health, Melbourne, Victoria, Australia.
• Intern Med J. 2021 Nov 1; 51 (11): 1862-1868.

BackgroundIatrogenic medication errors are a cause of medical morbidity and mortality. They result in significant cost to the Australian healthcare system each year. There is limited Australian evidence describing the iatrogenic errors occurring within the hospital system.AimsTo examine and describe iatrogenic medication errors occurring in Victorian healthcare settings through the analysis of referrals to a state Poisons Information Centre (PIC).MethodsA retrospective review of iatrogenic medication errors reported to the Victorian PIC (VPIC) from community and hospital healthcare settings from January 2015 to December 2019.ResultsOver a 5-year period, 357 iatrogenic errors were identified, 63% (n = 224) of which occurred in a hospital setting. The remaining errors occurred in a community healthcare setting. One in five patients were symptomatic from the medication error at the time of the call to the VPIC, and a change in management was required in 45% (n = 165) of all cases. Five percent (n = 17) of patients developed moderate to severe clinical toxicity as determined by the recorded poisoning severity score, and 88% (n = 18) of these required critical care management. Incorrect medication dosing accounted for 62% (n = 221) of errors. Common medication dosing errors included: double dose (51%, n = 114), incorrect medication administered (14%, n = 49), incorrect route (9%, n = 31), incorrect patient (6%, n = 22) and adult dose given to a child (4%, n = 15).ConclusionsIatrogenic errors are occurring in the Victorian health care system. These errors can result in serious morbidity. Identification of causative factors and investment in preventative strategies will likely reduce associated morbidity and healthcare costs.© 2020 Royal Australasian College of Physicians.

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