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Medication administration errors and mortality: Incidents reported in England and Wales between 2007 ̶ 2016

Harkanen, M; Vehviläinen-Julkunen, K; Murrells, T; Rafferty, AM; Franklin, BD; (2019) Medication administration errors and mortality: Incidents reported in England and Wales between 2007 ̶ 2016. Research in Social and Administrative Pharmacy , 15 (7) pp. 858-863. 10.1016/j.sapharm.2018.11.010. Green open access

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Abstract

Background Medication administration errors may contribute to patient mortality, thus additional understanding of such incidents is required. Objectives To analyse medication administration errors reported in acute care resulting in death, to identify the drugs concerned, and to describe medication administration error characteristics (location of error, error type, patient's age) by drug group. Methods Medication administration errors reported in acute care in 2007 ̶ 2016 (n = 517,384) were obtained from the National Reporting and Learning System for England and Wales. Incidents reported as resulting in death (n = 229) were analysed. Drugs were classified by two researchers using the British National Formulary. Drug categories were described by medication administration errors' year, location, patient age, and error category based on the incidents’ original classification. Results Errors were most often reported on wards (66.4%, n = 152), and in patients aged over 75 years (41.5%, n = 95). The most common error category was omitted medicine or ingredient (31.4%, n = 72); most common drug groups were cardiovascular (20.1%, n = 46) and nervous system (10.0%, n = 23). Most errors in patients under 12 years concerned drugs to treat infection; cardiovascular drugs were most common among other age groups. Conclusions In order to prevent these most serious of medication administration errors, 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.

Type: Article
Title: Medication administration errors and mortality: Incidents reported in England and Wales between 2007 ̶ 2016
Open access status: An open access version is available from UCL Discovery
DOI: 10.1016/j.sapharm.2018.11.010
Publisher version: https://doi.org/10.1016/j.sapharm.2018.11.010
Language: English
Additional information: This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Keywords: Adverse event, Death, Drug, Incident reporting, Medication administration, Patient safety
UCL classification: UCL
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy > Practice and Policy
URI: https://discovery.ucl.ac.uk/id/eprint/10064096
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