Medication incidents in a private hospital : frequency, type, causes and outcomes

Abstract

Background: Medication Safety has become a major health issue in Australia and internationally. Medication use is a part of most people lives with around seven in ten Australians and nine in ten older Australians having taken at least one medication over a two week period. But the taking of medications is not devoid of risk to the patient and a subsequent cost to society. This risk of an adverse outcome can be due to a predictable or idiosyncratic direct effect of the medication (adverse drug reaction) or a breakdown in the systems involved in the management of medications (medication incident). Although the risk of an adverse outcome is low and most medication incidents do not cause any harm, the volume of medications in use dictates that the problem when quantified is still significant. Following the publication of major patient safety studies it has become possible to estimate that almost 2 to 3 per cent of all hospital admissions are related to problems with medicines with an annual cost of $380 million.In 2002, following the publication of the Second National Report on Patient Safety ―Improving Medication Safety‖ it became apparent that despite medication safety issues growing in awareness in public hospitals, the same could not be said for private hospital practice which catered for about one third of all admitted patient episodes in Australia. Later that year a first step was taken with the Private Health Industry Quality and Safety workshop with representatives from most private hospitals attending. This meeting highlighted that medication safety practices at St John of God Hospital Subiaco was not aligned very well with public sector hospitals and that a number of deficiencies existed requiring urgent attention.Aims: This study had a broad range of aims. These were as follows: 1. To chronicle the development of medication safety procedures at St John of God Hospital Subiaco, nationally and internationally. 2. To quantify and uniformly classify, medication incidents reported from different sources in a private hospital. 3. To develop and assess a range of contributing factors as to why the medication incidents occurred. 4. To quantify the clinical significance of reported medication incidents. 5. To develop strategies to minimise/reduce the incidence of medication incidents in the future. 6. To investigate the influence of pharmacy ownership, location and employment of clinical pharmacists on medication incident reporting practices in Australian private hospitals.Method: The study was conducted in different phases. Initially the focus was a retrospective review of reported medication incidents in the hospital based on the date of occurrence of the medication incident rather than the date of review by a pharmacist. Secondly all incidents were then classified using a standardised format using the origin of the error. These included prescribing errors by medical practitioners, dispensing error by pharmacists and administration errors by nursing staff. Standard sub-categories were devised by St John of God Health Care, the national body coordinating the practices of all St John of God Hospitals, but in some instances they were noted to be too general. This led as part of this study to the development of more specific and sensitive categories for dispensing errors.Due to the realisation that medication error was now seen as a systems failure it was appropriate then to assess the risk to the patient and/or the organisation for a particular incident as well as determine some measure of harm to the patient. The level of risk associated with a medication incident was ranked according to the consequence of the incident and the likelihood of it recurring. Allied to this, a determinant of harm suffered by a patient following an incident or error was devised and promoted which differentiated harm into potential and actual harm.To further gauge private hospital medication safety practices, a national survey was undertaken of Australian private hospitals to gain an insight into the methodology used to collect and collate medication incidents and the roles played by pharmacy services in that process. In particular the survey sought to determine the influence of the ownership and location of the pharmacy service on those practices along with the employment or not of clinical pharmacists.Results: The classification of medication incidents by the date of occurrence aided in the assessment of why an incident occurred as it now became possible to study whether the ward location and day or time of an incident contributed in any way to causing that error. The classification of medication incidents by their origin in the medication cycle, highlighted that most incidents were reported by nursing staff and were therefore heavily weighted towards administration errors, which embodied their core medication function.The development of knowledge and understanding surrounding the causes and contributing factors associated, in particular with administration and dispensing medication errors, has helped to retrain caregivers to seek ways to avoid the incident in the future rather than focusing on any individual blame for what is a system failure.The clinical significance of a particular incident both to the patient and to an organisation can be more adequately assessed if a risk stratification and harm model is in place. This is apparent when dispensing errors were assessed as clinically significant to the pharmacy department but from a hospital perspective were noted only to have a potential for harm. In contrast, while the majority of administration errors had the potential for harm, some did cause actual harm.With the awakening of the need to improve our medication practices, the Pharmacy Department and the Hospital have committed to embracing more fully those practices more commonplace in public hospitals. These included having an active Drug and Therapeutics Committee and the implementation of clear medication polices and guidelines. Other initiatives have been embraced such as the use of standardised medication charts and ensuring a strong focus on medication reconciliation at the transitions of care. This included the employment of more clinical pharmacists to service areas such as preadmission and high risk areas such as Intensive Care and Oncology.The survey, with a response rate of 43%, highlighted that pharmacy services in private hospitals in Australia were either located On Site (52.8%) or Off Site (47.2%) and were either Hospital Owned (22.2%) or Contracted Out (77.8%). On Site pharmacy respondents were significantly more likely to be involved in the review of medication incidents (p = 0.047), have a policy on medication safety (p = 0.024), employ more clinical pharmacists (p = 0.006) and have a higher mean number of medication incidents reported (p = 0.001) as compared to Off Site pharmacies. Pharmacy providers who employed clinical pharmacists were more likely to be involved in the review of medication incidents (p = 0.02). Hospital Owned services were more likely to report a higher number of medication incidents (p = 0.011) and be On Site whilst Contracted Out services were more likely to be Off Site (p = 0.026).Medication safety has grown to become an international phenomenon. Two of the World Health Organisations top five priority areas to improve patient safety worldwide involve medication usage. In Australia, the formation of an active Australian Commission on Safety and Quality in Health Care, has provided leadership to all hospitals both private and public whilst at state level Medication Safety Groups drive more local state based issues. The willingness of some private hospitals to embrace fully the concept of medication safety is very evident at St John of God Health Care where a national medication reference group was set up to lead all their hospitals along a common path and this has been complemented recently by the formation of a medication safety committee at the Subiaco campus.Conclusion: The safe use of medicines is still a major issue. Medication errors are now recognised to be a system failure. Great progress has been made to improve the system of how we manage medications in our hospitals, but the system must continue to evolve. Gaps still exist that need addressing to make our hospitals safer. The various private hospital models that exist lend themselves to differing levels of service and participation in medication safety. It is vital that the Australian Council for Health Care Standards, the private health insurers and the Commonwealth Health Department develop a higher expectation from all private hospitals to ensure systems are in place so that patients are safe regardless of the health care environment they enter.