Factors causing medication errors in an electronic reporting system.
Seonhee Yoon, Kyeongyae Sohng
PMID 34392612WHAT IT FOUND
In one hospital, nurses' electronic reports yielded 805 analysed medication errors over five years.
Most were near misses. Errors detected by another person or during incident or record review were more likely to be adverse events than errors with unknown detection method.
Key findings
01Nurses' electronic reports yielded 632 near misses and 173 adverse events.
02After accounting for other variables, errors reported by another person or detected during an incident or EMR review were more likely to be adverse events than errors with unknown detection method.
03Clinical experience, work hours, detection time and location were factors affecting error type and harmfulness.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study analysed reports from one tertiary hospital in South Korea, so it may not apply to other settings. Medication errors are usually underreported, so the analysed reports may not represent all errors. Sentinel events were excluded, so the most serious outcomes are missing. The free-text descriptions entered by reporters were not analysed, so context behind each error is missing. Because detection method was optional and unknown for 221 reports, classification of how errors were found may be incomplete. The study is observational and cannot show that any factor caused an error.
Declared interests
The authors declared no conflicts of interest.
The easy way to misread this
Do not read these associations as proof that changing shift, nurse experience, detection method or location causes fewer medication errors. The study analysed existing reports from one hospital, and medication errors are usually underreported, so the patterns describe what was reported, not the true error rate.