Medication-related incidents at 19 hospitals: A retrospective register study using incident reports.
Maria Cottell, Inger Wätterbjörk, Maria Hälleberg Nyman
PMID 32802373WHAT IT FOUND
Most medication incidents happened during administration and prescribing, with wrong dose being the top error in both.
Nurses reported nearly all incidents, often catching physician errors. Only 3.7% of reported incidents caused patient harm, while most were near misses or errors that reached the patient without harm.
Key findings
01Administration (44.3%) and prescribing (40.6%) were the phases with the most incidents, with no significant difference between them.
02Wrong dose was the most common error in both the administration phase (N=82) and the prescribing phase (N=89).
0396.3% of incidents resulted in no harm to patients, while 3.7% caused harm of varying seriousness.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
Read the rest of this summary
You get three full summaries a month, free, and we do not ask for a card. Search, the TL;DRs and your library stay unlimited either way.
What it does not show
Only a fraction of all medication incidents are recorded in incident reporting systems, so the study represents a limited part of the total problem. Only 128 of the 775 reports had enough data to analyse causes and reporter professions, limiting the depth of the causal analysis. The categorisation of incidents was performed by a single author, although the process was reviewed by the co-authors. The study relies on self-reported perceptions of causes from the reporters, which may not reflect the actual systemic or human factors involved.
Declared interests
The authors declared no conflicts of interest. The study was supported by non-U.S. government funding.
The easy way to misread this
Do not interpret the low rate of harm (3.7%) as evidence that medication incidents are generally safe. The study explicitly notes that incident reporting systems capture only a fraction of all events, and severe incidents are often underreported. The high volume of near misses and errors reaching patients without harm indicates a fragile system where nurses are frequently catching errors, not that errors are rare or inconsequential.