| A review of medication incidents reported to the National Reporting and Learning System in England and Wales over six years (2005 - 2010). | |
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MedLine Citation:
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PMID: 22188210 Owner: NLM Status: Publisher |
Abstract/OtherAbstract:
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A review of all medication incidents reported to the National Reporting and Learning System (NRLS) in England in Wales between 1(st) January 2005 and 31(st) December 2010 was undertaken. The 526,186 medication incident reports represented 9.68% of all patient safety incidents. Medication Incidents from acute general hospitals (394,951) represented 75% of reports. There were relatively smaller numbers of medication incident reports (44,952) from primary care representing 8.5% of the total. Of 86,821 (16%) medication incidents reporting actual patient harm, 822 (0.9%) resulted in death or severe harm. Incidents involving medicine administration 263,228 (50%) and prescribing 97,097(18%) were the process steps with the largest number of reports. Omitted and delayed medicine 82,028 (16%) and wrong dose 80,170 (15%) represented the largest error categories. Thirteen medicines or therapeutic groups accounted for 377 (46%) of the incidents with outcomes of death or severe harm. The NPSA has issued guidance to help minimise incidents with many of these medicines. Many recent incidents could have been prevented if the NPSA guidance had been better implemented. It is recommended that healthcare organisations in all sectors establish an effective infrastructure to oversee and promote safe medication practice, including an annual medication safety report. In the future, preventable harms from medication incidents can be further minimised by the continued use of the NRLS to identify and prioritise important actions to improve medication safety, a central organisation continuing to issue medication safety guidance to the service and better methods to ensure that the NHS has implemented this guidance. |
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Authors:
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Dh Cousins; D Gerrett; B Warner |
Publication Detail:
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Type: JOURNAL ARTICLE Date: 2011-12-22 |
Journal Detail:
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Title: British journal of clinical pharmacology Volume: - ISSN: 1365-2125 ISO Abbreviation: - Publication Date: 2011 Dec |
Date Detail:
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Created Date: 2011-12-22 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 7503323 Medline TA: Br J Clin Pharmacol Country: - |
Other Details:
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Languages: ENG Pagination: - Citation Subset: - |
Copyright Information:
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© 2011 The Authors. British Journal of Clinical Pharmacology © 2011 The British Pharmacological Society. |
Affiliation:
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FRPharmS is Head of Patient Safety, Safe Medication Practice and Medical Devices at the National Patient Safety Agency. MRPharmS. is Senior Pharmacist, Safe Medication Practice and Medical Devices at the National Patient Safety Agency. MRPharmS is Associate Director of Patient Safety at the National Patient Safety Agency. |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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