Describing and Quantifying Wrong-Patient Medication Errors Through a Study of Incident Reports

Abstract

Megumi Takahashi,1 Hiroshi Okudera,2 Masahiro Wakasugi,2 Mie Sakamoto,2 Hiromi Shimizu,3 Tokie Wakabayashi,3 Tsuneaki Yamanouchi,3 Hisashi Nagashima2 1Department of Quality and Patient Safety, Tokyo Medical University, Tokyo, Japan; 2Department of Crisis Medicine and Clinical Safety, University of Toyama, Toyama, Japan; 3Department of Medical Management Office, Toyama University Hospital, Toyama, JapanCorrespondence: Megumi Takahashi, Department of Quality and Patient Safety, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku, Tokyo, Japan, Tel [phone] Ext 3939, Fax [phone], Email [email protected]: Our aim was to inform a new definition of wrong-patient errors, obtained through an analysis of incident reports related to medication errors.Methods: We investigated wrong-patient medication errors in incident reports voluntarily reported by medical staff using a web-based incident reporting system from 2015 to 2016 at a university hospital in Japan. Incident report content was separately evaluated by four evaluators using investigational methods for clinical incidents from the Clinical Risk Unit and the Association of Litigation and Risk Management. They investigated whether it was the patient or drug that was incorrectly chosen during wrong-patient errors in drug administration in incident reports and assessed contributory factors which affected the error occurrence. The evaluators integrated the results and interpreted them together.Results: Out of a total 4337 IRs, only 30 cases (2%) contained wrong-patient errors in medication administration. The cases where the intended drugs were administered to incorrect patients occurred less frequently than cases where the wrong drugs were administered to the intended patients through the investigation of wrong targets. After a discussion, the evaluators concluded that the patient - drug/CPOE screen mismatch, caused by choosing the wrong patient, drug, or CPOE screen (mix-ups), occurred in the wrong-patient medication errors. These errors were caused by three conditions: (1) where two patients/drugs were listed next to one another, (2) where two patients’ last names/drugs’ names were the same, and (3) where the patient/drug/CPOE screen in front of the staff involved was believed to be the correct one. Additionally, these errors also involved insufficient confirmation, which led to failure to detect and correct the mismatch occurrences.Conclusion: Based on our study, we propose a new definition of wrong-patient medication errors: they consisted of choosing a wrong target and insufficient confirmation. We will investigate other types of wrong-patient errors to apply this definition.Keywords: wrong-patient error, medication error, web-based incident reporting system, computerized physician order entry, human error

Keywords

• wrong-patient error
• medication error
• web-based incident reporting system
• computerized physician order entry
• human error