A 3-year study of medication incidents in an acute general hospital.

BACKGROUND AND OBJECTIVE

Inappropriate medication use may harm patients. We analysed medication incident reports (MIRs) as part of the feedback loop for quality assurance.

METHODS

From all MIRs in a university-affiliated acute general hospital in Hong Kong in the period January 2004-December 2006, we analysed the time, nature, source and severity of medication errors.

RESULTS

There were 1278 MIRs with 36 (range 15-107) MIRs per month on average. The number of MIRs fell from 649 in 2004, to 353 in 2005, and to 276 in 2006. The most common type was wrong strength/dosage (36.5%), followed by wrong drug (16.7%), wrong frequency (7.7%), wrong formulation (7.0%), wrong patient (6.9%) and wrong instruction (3.1%). 60.9%, 53.7% and 84.0% of MIRs arose from handwritten prescription (HP) rather than the computerized medication order entry in 2004, 2005 and 2006 respectively. In 43.1% of MIRs, preregistration house officers were involved. Most errors (80.2%) were detected before any drug was wrongly administered. The medications were administered in 212 cases (19.7%), which resulted in an untoward effect in nine cases (0.8%).

CONCLUSIONS

The most common errors were wrong dosage and wrong drug. Many incidents involved preregistration house officers and HPs. Our computerized systems appeared to reduce medication incidents.