Factors contributing to reported medication administration incidents in patients' homes - A text mining analysis.
Marja Härkänen, Bryony Dean Franklin, Trevor Murrells and 2 others
PMID 33048380WHAT IT FOUND
The most common reported home care medication incidents were missed doses or patients not taking drugs.
The most common contributing factor was information not reaching staff. 40.1% caused mild harm.
Key findings
01The most common incident types were omissions of drug doses (47.4%, N = 9,343) and patient did not take the drug (29.6%, N = 5,843).
02The most commonly reported contributing factor was communication and flow of information (25.5%, N = 5,038).
03Mild harm was reported in 40.1% (N = 7,915), moderate harm in 5.3% (N = 1,047), and serious harm in 0.1% (N = 22).
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The data were voluntary incident reports, so many medication incidents, especially near misses, may not have been reported. Harm, incident type and contributing factors were classified by handlers after the report was filed, so they may not be uniform. The researchers chose keywords subjectively from free text, and some relevant terms may have been missed. The free text was in Finnish and translated into English, so wording in examples may not exactly match the original. The dataset came from one city's home care services, so it may not represent other home care settings.
Declared interests
The funding statement names the Academy of Finland. The supplied text does not report other competing interests.
The easy way to misread this
Do not conclude that communication breakdowns caused 25.5% of all home care medication incidents. These were voluntary incident reports, likely under-reported, and contributing factors were classified from report text rather than directly observed.