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

OBJECTIVE

To 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.

METHOD

Retrospective 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 MEASURES

Frequency 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.

RESULTS

Over 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.

CONCLUSION

An 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.