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Mark McCullagh, Pharmacist and Clinical Risk Advisor, presents data relating to medication incidents reported on the National Incident Management System (NIMS), 2019 – 2022, and presents advice on how to improve medication safety in the health and social care sector.

A medication incident is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. The terms medication incident and medication error are similar.

Nationally and internationally, the majority of reported medication incidents do not result in patient harm. However, it is important to acknowledge that the subset of medication incidents that do result in harm can have a serious impact on service users and their families/caregivers. Most harm resulting from healthcare interventions is preventable. Medicines are the most common therapeutic intervention.

Medication error is the leading cause of avoidable patient harm. The cost of medication errors worldwide has been estimated at $42 billion USD per annum. The current (third) WHO Global Patient Safety Challenge is Medication Without Harm and aims to reduce severe avoidable medication-related harm by 50% globally over five years. Reducing medication-related harm is also a priority of the HSE Patient Safety Strategy, 2019 – 2024.

You can download a copy of our Medication Incidents infographic below:

Incident reporting affords health and social care services the opportunity to learn from adverse incidents. However, internationally it is estimated that less than 1% of medication incidents are identified by spontaneous reporting.

Mark McCullagh Pharmacist and Clinical Risk Advisor

Learning from reported incidents

Incident reporting affords health and social care services the opportunity to learn from adverse incidents. However, internationally it is estimated that less than 1% of medication incidents are identified by spontaneous reporting.

In Ireland, publicly funded health and social care services have a statutory obligation to report incidents, including medication incidents, to the State Claims Agency on NIMS. The State Claims Agency supports health and social care services in fulfilling this legal obligation and periodically publishes national incident and claims data to foster, promote and disseminate learning, in line with our statutory risk management mandate. In contrast to previous medication incident reports published by the State Claims Agency, this data for 2019 – 2022 includes medication incidents reported in community healthcare organisations and related agencies, in addition to hospitals.

What does our analysis show?

  • 93.9% of medication incidents were reported with a negligible (no harm) severity rating.
  • The medication name was not recorded in 10% of medication incidents reported on NIMS, signalling that a renewed focus on data quality is required.
  • Medication incidents related to COVID-19 vaccines contributed to an increase in the number of medication incidents reported in 2021.
  • Administration incidents and prescribing incidents accounted for the majority of medication incidents by stage of process.
  • 45.2% of medication incidents were reported by nursing and midwifery staff and a further 41.6% by Allied Health Professionals, which includes pharmacists, indicating the valuable role these staff groups play in identifying and reporting medication incidents.
  • Only 3.9% of medication incidents were reported by medical staff i.e., doctors, indicating that this is an area for improvement.
  • The medication subgroups most frequently featured in medication incidents were, in descending order, antithrombotics, antiepileptics, opioids, antipsychotics and viral vaccines. There was a spike in incidents in this latter group in 2021, coinciding with the rollout of the COVID-19 vaccines.

How can medication safety be improved?

Both health and social care services and health and social care professionals have important roles to play in improving medication safety.

Health and social care services:

  1. Consider adopting a standardised prescription chart, which has been shown to reduce prescribing errors.
  2. Ensure clinical areas have access to clinical pharmacy services and medication reconciliation occurs at transitions in care.
  3. Allocate dedicated time for staff education and training on safe medication practices; target incident reporting awareness training at medical staff to improve reporting levels.
  4. Where resources allow, consider introducing electronic prescribing systems, which have been shown to reduce prescribing errors.
  5. Quality assure data logged on NIMS to ensure that the names of medications involved in incidents are recorded accurately.

Health and social care professionals:

  1. Health and social care professionals should use two patient identifiers to ensure the correct patient is selected before prescribing, dispensing, or administering medication.
  2. Prescribers should establish and document an accurate medication history and drug allergy history prior to prescribing new medication.
  3. Prescribers should consult a recognised reference source when prescribing new or unusual medication.
  4. Health and social care professionals preparing medication requiring reconstitution, or for which a dose calculation is required, should ensure their work is double-checked by a colleague.
  5. Health and social care professionals involved in, or who discover, a medication incident should report the incident on NIMS, ensuring the medication name is captured.

References are available on request.

Clinical Risk Insights

Check out more articles from the latest edition of Clinical Risk Insights by the State Claims Agency.

Clinical Risk Insights

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