Risk Analysis of Errors in Prescribing, Dispensing and Administering Medications within a District Hospital

Abstract

ABSTRACT Aim To investigate errors in prescribing, dispensing and administering medications, determine the origin of the error and analyse the risks according to established risk‐rating matrices. Method Errors detected by pharmacists were recorded and combined with errors recorded by nurses and doctors. Errors were classified by type of event, source of report and professional group responsible for the occurrence. Errors were evaluated against two risk‐rating matrices developed by Queensland Health and Standards Australia. Results Reported errors occurred at the rate of 1.8% of drugs prescribed over the period from admission to discharge. There were no dispensing errors reported during the study period. Nurses reported 150 incidents and pharmacists detected 275. In the majority of cases it was possible to identify the node in the medication‐use process that was associated with the error (35% administering and 53% prescribing) but this was not possible in 12% of cases. The two largest categories of errors were incorrect dose prescribed (29%) and dose not recorded as given (28%). There was a marked difference in risk profile between the two risk‐rating matrices. Conclusion The majority of errors were due to performance lapses or lack of knowledge. The difference in risk profiles suggests that hospitals should adopt a uniform risk‐rating matrix for benchmarking purposes. To avoid underestimates of hospital error rates, a reporting system that can interface with pharmacy information‐management systems needs to be developed.