‘Each death caused by medication error is one death too many’

Which medication administration errors are most commonly implicated in deaths? A new large study investigates

A retrospective study has looked at medication administration errors reported in acute care, analysing which errors were most common and the types of drugs involved.

Finnish and British researchers obtained data on medication administration errors reported in acute care from 2007-2016 (= 517,384) across England and Wales.

Incidents reported as resulting in death (n = 229) were analysed.

Errors were most often reported on wards (66.4%) and in patients aged over 75 years (41.5%).

The most common error was omitted medicine or ingredient (31.4%).

Reasons for medication omissions are “manifold”, such as staff shortages, delays in medications dispensing, patients’ inability to take the medicine, or medication unavailability, explained the researchers.

More attention is needed on omissions since the consequences can be serious, they said.

The most common drug groups implicated in medication administration errors were cardiovascular (20.1%) – the most common of these being parenteral anticoagulants – followed by nervous system drugs (10%) – of which analgesics were most common.

Other common drugs groups involved in errors were antibacterials, cytotoxic drugs, and insulin.

Errors occurring in intensive care units most commonly concerned drugs used in blood and nutrition, and infection.

The findings show that more attention should be paid to the safe administration of medication, especially when it comes to older people, said lead author Marja Härkänen, a postdoctoral researcher at the University of Eastern Finland.

“It is important to make sure that the patients gets the right dose of medication at the right time and in the right way.”

“Each death caused by medication error is one death too many,” said the researchers.

“More knowledge and competence in handling drugs and administration of drugs should be provided to all health professionals, especially nurses, as they are usually the final step in the medication use process.

“Interventions should focus on avoiding dose omissions, and administration of drugs for patients over 75 years old, as well as safe administration of parenteral anticoagulants and antibacterial drugs.”

The findings were newly published in Research in Social and Administrative Pharmacy.

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  1. Michael Khoo

    Wouldn’t it be great to expand the clinical role of pharmacists to help deal with this?…. oh…wait……

    • Ron Batagol

      It’s, for all of us, perhaps stating the obvious- It is critical, always has been, but now even more so, with the recent advent of a vast array of new drugs- MABs etc. for so many different diseases, that pharmacists, the acknowledged experts in medication management, become universally recognised and utilised in this role and, of course remunerated accordingly. You don’t need to be a financial guru, to realise that using medication experts to PREVENT potential adverse medication outcomes, is a safety and cost-effective measure- Indeed it’s a “no brainer”.!

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