System approach of medication error in Prapokklao Hospital.

Abstract

Introduction. A System Approach in medication error had been carried out at Prapokklao Hospital. The study was relevant to how we safely performed any given medication to our patients.These included errors in prescription, order processing (transcribing and pre-dispensing errors),dispensing and administration respectively.

Objective. To study the frequency and types of medication error. Root Cause Analysis (RCA) was also studied to obtain consensus guidelines in correction and prevention from its occurrence
in our hospital.

Method. Descriptive study was done retrospectively for all consecufively medication errors reported from April 1st to November 30th, 2003 in outpatient and inpatient groups. All incident reports as sentinel events were also collected for intensive analysis to find out any root causes and correction plan, recommended by Joint Commission on Accreditation of Healthcare Organization (JCAHO).

Result. During 8 months, 147,982 prescribing orders in outpatient were considered (average of 3.3 items of medication for each order).Medication errors were found in all steps as prescribing error, transcribing error to microcomputer,pre-dispensing error and dispensing error in 3.70, 10.35, 8.89 and 0.26 orders respectively for every 1,000 orders.For inpatient study of 138,377 orders (average of 7.13 medication items per order),medication errors as prescribing error, transcribing error to microcomputer, transcribing error to medication card, pre-dispensing error, dispensing error and administration error were 0.45, 7.62, 0.26,33.00, 0.71 and 0.97 orders respectively for every 1,000 orders.

Root cause analysis was done whenever there is any of the following risk to the patient was found. These included error from medication already given or omitted to our patients, error related to high-risk medication in our list and high incidents,which occurred more frequent than the target for each type of error.

Various factors in the system could contribute to cause the error. 25 outpatient sentinel events had been reviewed during the study period.Root causes were as follows : physical environment 24 percent, staffing level 17 percent and supervision 12 percent. There were 69 sentinel events for inpatient. The root causes were identified as : supervision 30 percent, communication among staff members 26 percent and staffing level 11 percent. RCA was done and correction plans were proposed by our responsible, peer review teams and subsequently presented to Drug Utilization and Safety (DUS) committee.

Discussion. The goal of medication therapy is the achievement of defined therapeutic outcomes that improve quality of life while minimizing patient risk. All types of adverse drug events had been studied in our hospital for their incidence and severity. We tried recently to organize our segmental infrastructure to solve and eliminate the high risk incidents for patient safety. As a quality hospital, effective multidisciplinary teams had been settled to study RCA. This strategy was successfully performed with systematic approach. All of the risk occurred was evaluated together with difficulty. Thank to the perseverance of our DUS committee, which had
been supported by hospital committee (Pharmacy and therapeutic committee-PTC). 

The spirit of team for interdepartmental coordination is our key success factor. We are very proud of the new established organization culture.It should be noted that human mistake was not our blame for the causes of such events. This has been proved by our reporting system particularly sentinel events which were considerably high from various units. All of them were subsequently analyzed for the root causes and implemented effective guidelines to prevent recurrence. The surveillance system had also been performed continuously for this clinical risk.

However, our systematic approach for medication error remains to be improved further.It is to make sure that all incidents will be detected and root cause analysis process of each team is effectively achieved. This has been our dilemma because we could not assure that the lesser incidents are the results from any of them.Open up communication and availability of drug information is also the key. Moreover, the outcomes and expenditure of these sentinel events have not yet successfully been reported.Active role to find out all incidents as much as extensive study of the revised high-risk medication to minimize any type of our medication error for patient safety is still needed for our hospital in the future.