(138) Medication Errors Reported to The Danish Patient Safety Database During a Five-Year Period (2014-2018)

Saturday, August 27, 2022

8:00 AM – 6:00 PM CEST

Location: Hall C

Publication Number: 812

Presenting Author(s)

Olga Tchijevitch
– University of Southern Denmark (Department of Clinical Research), University of Southern Denmark, Odense C, Syddanmark, Denmark

Co-Author(s)

Jesper Hallas, MD, PhD, FISPE
– University of Southern Denmark, Odense C, Syddanmark, Denmark
Søren Bie Bogh
– Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Region of Southern Denmark, Denmark
Søren Birkeland
– Research Unit OPEN, Department of Clinical Research, University of Southern Denmark , Region of Southern Denmark, Denmark

Background: In Denmark, medication errors (MEs), must be reported to the patient safety reporting system the Danish Patient Safety Database (DPSD). Medication incidents constitute the largest category of the reported patient safety events.

Objectives: We aimed to describe the magnitude and characteristics of MEs reported to DPSD and identify medications associated with an increased risk of error-related harm.

Methods: We conducted a cross-sectional descriptive study on medication incident reports on patients aged > 18, submitted to DPSD in 2014-2018.

Results: We performed a two-step descriptive analysis on 1) medication incidents and 2) single MEs, as a medication incident may involve MEs with multiple drugs. Analysis on 479,814 reported medication incidents revealed that the largest share of reports was related to community residential nursing (44.6 %). Only 1.16% of the reports represented general practitioners and 0.51% pharmacies. Most of the events were harmless (70.87%) and 0.8 % had caused severe harm and death. ME-analysis was performed on reports with available information on drugs. In total, 444,555 reports were analyzed. Paracetamol and Furosemide were the most frequently reported medications related to harmful MEs in 8.74% vs. 3.00%. For the ratio on harmful MEs in relation to all MEs for a given drug, morphine and warfarin were the drugs most commonly associated with harm. Similarly, transdermal and intrathecal routes of administration, “wrong patient”, and “wrong route” MEs were associated with most harm. Warfarin, methotrexate, potassium chloride, paracetamol, and morphine were the medications most often involved in fatal MEs.

Conclusions: In this descriptive study we found a large proportion of harmless medication incident reports and reports from community healthcare services in the database. The drugs and the dispensing circumstances that are well established as carrying particular risks were prominent in this analysis as well.