Disproportionality Analysis Used to Identify Patterns in Medication Error Reports Involving Hospitalized Children

Abstract Objective To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the pre- and post-guideline phase). Design A cross-sectional study. Setting Medication errors reported to the Central Medication incidents Registration reporting system. Participants Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR. Intervention N/A. Main outcome measure Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the pre- and post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline. Results Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline. Conclusions Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.

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Analysis of Medication Error Reports

Engineering/Technology Management: Safety Engineering and Risk Analysis, Technology and Society, Engineering Business Management ◽

10.1115/imece2004-61182 ◽

2004 ◽

Author(s):

Paul Whitney ◽

Jonathan Young ◽

John Santell ◽

Rodney Hicks ◽

Christian Posse ◽

...

Keyword(s):

Data Analysis ◽

Medication Error ◽

Medication Errors ◽

Free Text ◽

Area Of Interest ◽

Analysis Tools ◽

Depth Analysis ◽

Reporting Programs ◽

Types Of Information ◽

Error Reports

In medicine, as in many areas of research and society, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been a corresponding lag in our abilities to analyze this mass of data, and traditional forms and expressions of statistical analysis do not allow researchers and practitioners to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports are approached as data comparisons, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Additionally, the “types” of information objects that can be the objects of data analysis have been extended to include text [8][9]. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. USP conducts an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.

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ISMP Medication Error Report Analysis - Leucovorin-Levoleucovorin Mix-Up; Two Error-Reduction Principles, One Change; Syringe Pull-Back Method of Verifying IV Admixtures is Unreliable; Fleet Enema Saline is not Just Saline; ISMP Processes Health it Error Reports

Hospital Pharmacy ◽

10.1310/hpj4810-803 ◽

2013 ◽

Vol 48 (10) ◽

pp. 803-806 ◽

Cited By ~ 1

Author(s):

Michael R. Cohen ◽

Judy L. Smetzer

Keyword(s):

Medication Error ◽

Error Reduction ◽

Health It ◽

Report Analysis ◽

Error Reports

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Pediatric Medication Error Reports in Korea Adverse Event Reporting System Database, 1989-2012: Comparing with Adult Reports

Journal of Korean Medical Science ◽

10.3346/jkms.2015.30.4.371 ◽

2015 ◽

Vol 30 (4) ◽

pp. 371 ◽

Cited By ~ 9

Author(s):

Yeonju Woo ◽

Hyung Eun Kim ◽

Sooyoun Chung ◽

Byung Joo Park

Keyword(s):

Adverse Event ◽

Medication Error ◽

Reporting System ◽

Adverse Event Reporting System ◽

Adverse Event Reporting ◽

Event Reporting ◽

System Database ◽

Error Reports

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The Prevalence, Barriers to Medication Error Reports, and Perceptions of Nurses toward the Causes of Medication Errors in the Hospitals Affiliated to North Khorasan University of Medical Sciences, Iran

Iran Journal of Nursing ◽

10.29252/ijn.32.117.58 ◽

2019 ◽

Vol 32 (117) ◽

pp. 58-68

Author(s):

M Ghorbanzadeh ◽

S Gholami ◽

A Sarani ◽

F Badeli ◽

F Nasimi ◽

...

Keyword(s):

Medication Error ◽

Medication Errors ◽

Medical Sciences ◽

Error Reports

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Patterns of medication errors involving pediatric population reported to the French Medication Error Guichet

Pharmacy Practice ◽

10.18549/pharmpract.2021.2.2360 ◽

2021 ◽

Vol 19 (2) ◽

pp. 2360

Author(s):

Christine Azar ◽

Delphine Allué ◽

Marie B. Valnet-Rabier ◽

Laurent Chouchana ◽

Fanny Rocher ◽

...

Keyword(s):

Medication Error ◽

Medication Errors ◽

Pediatric Population ◽

Hospital Setting ◽

Community Setting ◽

Blood Substitutes ◽

Community Settings ◽

Prevention Measures ◽

Error Type ◽

Error Reports

Background: Medication error is a global threat to patient safety, particularly in pediatrics. Yet, this issue remains understudied in this population, in both hospital and community settings. Objectives: To characterize medication errors involving pediatrics reported to the French Medication Error Guichet, and compare them with medication errors in adults, in each of the hospital and community settings. Methods: This was a retrospective secondary data analysis of medication errors reported throughout 2013-2017. Descriptive and multivariate analyses were performed to compare actual and potential medication error reports between pediatrics (aged <18 years) and adults (aged >18 and <60 years). Two subanalyses of actual medication errors with adverse drug reaction (ADR), and serious ADR were conducted. Results: We analyzed 4,718 medication error reports. In pediatrics, both in hospital (n=791) and community (n=1,541) settings, antibacterials for systemic use (n=121, 15.7%; n=157, 10.4%, respectively) and wrong dose error type (n=391, 49.6%; n=549, 35.7%, respectively) were frequently reported in medication errors. These characteristics were also significantly more likely to be associated with reported errors in pediatrics compared with adults. In the hospital setting, analgesics (adjusted odds ratio (aOR)=1.59; 95% confidence interval (CI) 1.03:2.45), and blood substitutes and perfusion solutions (aOR=3.74; 95%CI 2.24:6.25) were more likely to be associated with reported medication errors in pediatrics; the latter drug class (aOR=3.02; 95%CI 1.59:5.72) along with wrong technique (aOR=2.28; 95%CI 1.01:5.19) and wrong route (aOR=2.74; 95%CI 1.22:6.15) error types related more to reported medication errors with serious ADR in pediatrics. In the community setting, the most frequently reported pediatric medication errors involved vaccines (n=389, 25.7%). Psycholeptics (aOR=2.42; 95%CI 1.36:4.31) were more likely to be associated with reported medication errors with serious ADR in pediatrics. Wrong technique error type (aOR=2.71; 95%CI 1.47:5.00) related more to reported medication errors with ADR in pediatrics. Conclusions: We identified pediatric-specific medication error patterns in the hospital and community settings. Our findings inform focused error prevention measures, and pave the way for interventional research targeting the needs of this population.

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