• Pharm World Sci · Dec 2006

    Retrospective analysis of medication incidents reported using an on-line reporting system.

    • Darren M Ashcroft and Jonathan Cooke.
    • School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Oxford Road, M13 9PL, Manchester, UK. darren.ashcroft@manchester.ac.uk
    • Pharm World Sci. 2006 Dec 1; 28 (6): 359-65.

    ObjectiveTo examine the types of prescribing, administration and dispensing incidents reported to an on-line incident-reporting scheme and determine the types of healthcare professionals responsible for reporting such incidents.MethodRetrospective analysis of medication-related incidents reported to an on-line incident-reporting scheme in a large (1000-bed) teaching hospital in the UK.Main Outcome MeasuresFrequency and type of incidents, the discipline of the health care professional who reported the incident and the stage in the medication use process (prescribing, dispensing, or administration) at which the incident occurred.ResultsOver a 26-month study period, there were 495 medication-related incidents reported, of which 38.6% (191) were classified to be a "near miss". Medication-related incidents were reported most often at the stages of administration (230, 46.5%) and prescribing (192, 38.8%), whilst incidents involving dispensing or supply of medication were reported less often (73, 14.7%). Of all the incidents, pharmacists reported 51.9% (257), nursing staff reported 37.6% (186), and doctors reported 9.1% (45). Cardiovascular (149, 30.1%), central nervous system (106, 21.4%), and antibiotic/anti-infective medication (71, 14.3%) were the most common therapeutic categories associated with reports of medication-related incidents.ConclusionAn on-line reporting scheme can be used to monitor medication-related incidents at key stages in the medication-use process in secondary care. The types of incidents reported by health care professionals differ markedly, with fewer medication-related incidents being reported by doctors. Future research should explore the prevailing safety culture amongst the different health care disciplines, and examine the impact that information technology has on the willingness of health care professionals to report adverse incidents.

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