Workshop 3: Learning from medication errors

ACPE UAN: 0475-0000-19-027-L04-P. A application based activity.

Linked to EAHP statements

Section 5 – Patient Safety and Quality Assurance: Statements 5.2, 5.4, 5.5, 5.6

Abstract

Medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is under the control of a health care professional, patient or consumer. These errors occur at all stages in medication use: ordering, prescription, dispensing and administration. Medication errors have significant implications on patient safety and their rates have been quoted to be in the region of 5-15 % per hospital admission in the developed world.

There are multiple tools for error detection. For instance medication errors can be detected by voluntary reporting, direct observation or chart review. Each method requires different re-sources and may determine the choice. The willingness to identify errors indicates a culture of safety and improvement. However, converting the collected data into real system change can be challenging, but the use of quality improvement tools and improvement science can facilitate this. Sharing the learning from medication errors that occur in practice is one of the best ways to prevent repeat occurrences. In a culture of safety, all errors should be viewed as learning opportunities, and information gathered from error analyses should be used to improve medication safety processes.

Learning objectives

After the workshop, participants should be able to:
• explain why medication errors occur;
• identify which actions can be taken to improve patient safety;
• identify local policies and procedures to improve safety of care to patients.

Educational need addressed

This workshop shares best practice for the prevention of medication errors and supports pharmacist involvement in minimizing medication errors.

Keywords | Medication errors, error detection, patient safety, learning.

Handouts: Yogini Jani & Carita Linden-Lahti