Mark McCullagh, Clinical Risk Adviser, presents a selection of National Incident Management System (NIMS) data on medication incidents reported by Irish hospitals in 2018.

What is a medication incident?

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.¹ The terms ‘medication incident’ and ‘medication error’ are similar.

Incidents created in 2018

What is the medication use process?

The medication use process describes the sequence of stages of medication utilisation from prescribing, transcribing, dispensing, administration through to monitoring.²

What is medication reconciliation?

Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points.³

Did you know?

• A recent study across primary and secondary care estimated that 237 million medication errors occur at the various stages of the medication use process each year in England, of which 25.8% and 2% have the potential to cause moderate and severe harm respectively.²
• This same study estimated the cost to the NHS of definitely avoidable adverse drug reactions (ADRs) to be £98.5 million (€115.3 million) annually.
• The World Health Organisation launched its third Global Patient Safety Challenge in 2017. Entitled Medication without Harm, the aim of this challenge is to reduce severe avoidable harm related to medications by 50% over five years.⁴

What can hospitals do to improve medication safety?

• Provide medication safety education and training for health and social care professionals
• Ensure availability of a recognised reference source(s) at the point of prescribing
• Develop a safe prescribing guide/app to ensure non-consultant hospital doctors have access to evidence-based current prescribing guidelines
• Ensure clinical areas have access to clinical pharmacy services
• sure medication reconciliation at transfers between care settings
• Empower the patient or carer through participation in programmes such as the HSE’s ‘Know, Check, Ask’ safer medicines campaign
• Encourage medication incident reporting and timely uploading to NIMS to allow detection of trends and clusters at both local and national level

A new report on medication incidents reported by Irish hospitals in 2017 and 2018 is due to published by the SCA later in the year.

References available on request.