What Are Incident Reports Telling Us?
What Are Incident Reports Telling Us?
A total of 12 567 prescribing errors were identified at audit across the two hospitals. The majority 68.9% (n = 8664) were procedural errors (e.g. missing allergy identification). Clinical errors constituted 31.1% (n = 3903) and 539 (4.3%) were rated as clinically important errors (Table 2).
During the period covered by the record audit, 15 prescribing errors were reported to the hospitals' incident systems. All incident reports identified prescribing errors found at audit. Thirteen (87%) of the 15 incidents related to clinical prescribing errors, and two were procedural errors.
There was a very low rate at which prescribing errors identified at audit had a matching incident report (Table 2), with 1.2 incident reports per 1000 identified errors. Incident reporting rates were higher for clinical errors, at 3.3 per 1000 identified clinical prescribing errors. The highest reporting rate was for clinically important prescribing errors at 13.0 reports per 1000.
Table 3 reports a sample of prescribing errors with incident reports. Table A2 shows a sample of clinically important prescribing errors identified at audit for which there was no incident report.
Of the 12 567 prescribing errors identified at audit, there was evidence that 1282 (10.2%) had been detected by hospital staff (n = 1277), or patients (n = 5) (Table 4). Of errors detected, pharmacists identified over two thirds (Table 4). Only 15 prescribing errors were reported in a total of 7 incident forms, as two patients had multiple errors documented in the same report. All incident reports were made by nurses. Table A1 summarizes the five errors detected by patients, which included no clinically important errors.
Of the clinically important prescribing errors identified at audit, 21.9% (n = 118) had been detected, of which seven had an incident form. Table 2 presents a summary of the rates at which prescribing errors were identified at audit, detected by staff and reported to the incident systems, by hospital. Figure 1a shows the distribution of prescribing errors identified, detected and reported and Fig. 1b shows this information for clinically important prescribing errors.
(Enlarge Image)
Figure 1.
Distribution of (a) prescribing errors observed by researchers, and detected and reported by clinical staff; (b) clinically important prescribing errors observed by researchers, and detected and reported by clinical staff.
For the 3291 patient admissions reviewed, 539 had clinically important prescribing errors, a rate of 16.4/100 patient admissions. Of these, 118 were detected by staff, a rate of 3.6/100 admissions and the rate at which these were reported via the incident reporting systems was 0.21/100 admissions (n = 7).
We examined each hospital's data. At Hospital A, 8621 prescribing errors were identified at audit for 1948 patient admissions, a rate of 4.43/100 admissions. At Hospital B, 1530 prescribing errors for 1343 admissions (1.14/100) were found at audit. However, the number of reported incidents for Hospital A was 0.34/1000 prescribing errors and for Hospital B 3.04/1000 prescribing errors (Table 2). Thus, Hospital A with the higher overall prescribing error rate had an incident reporting rate significantly lower than Hospital B (P < 0.0001).
The direct observational study of 7451 drug administration yielded 10 955 medication administration errors. Of these, the vast majority (79%) were procedural errors (e.g. failing to check a patient's identification prior to drug administration). One or more clinical errors occurred in 27.4% (n = 2043; 95% CI: 26.4–28.4%) of drugs administered. 10.2% (n = 209; 95% CI: 8.9–11.5%) of all drug administrations involved errors which were rated as clinically important.
Of the 10 955 administration errors observed none had an incident report. Table A3 provides examples of clinically important medication administration errors observed. We had no information about administration errors detected by staff. During the period of the observational study, 173 medication administration errors, involving administrations not observed by the research staff, were reported to the hospitals' incident systems.
Results
Comparison of Prescribing Errors Observed at Audit With Those Reported to the Hospitals' Incident Reporting Systems
A total of 12 567 prescribing errors were identified at audit across the two hospitals. The majority 68.9% (n = 8664) were procedural errors (e.g. missing allergy identification). Clinical errors constituted 31.1% (n = 3903) and 539 (4.3%) were rated as clinically important errors (Table 2).
During the period covered by the record audit, 15 prescribing errors were reported to the hospitals' incident systems. All incident reports identified prescribing errors found at audit. Thirteen (87%) of the 15 incidents related to clinical prescribing errors, and two were procedural errors.
There was a very low rate at which prescribing errors identified at audit had a matching incident report (Table 2), with 1.2 incident reports per 1000 identified errors. Incident reporting rates were higher for clinical errors, at 3.3 per 1000 identified clinical prescribing errors. The highest reporting rate was for clinically important prescribing errors at 13.0 reports per 1000.
Table 3 reports a sample of prescribing errors with incident reports. Table A2 shows a sample of clinically important prescribing errors identified at audit for which there was no incident report.
Prescribing Errors Detected by Staff and Patients
Of the 12 567 prescribing errors identified at audit, there was evidence that 1282 (10.2%) had been detected by hospital staff (n = 1277), or patients (n = 5) (Table 4). Of errors detected, pharmacists identified over two thirds (Table 4). Only 15 prescribing errors were reported in a total of 7 incident forms, as two patients had multiple errors documented in the same report. All incident reports were made by nurses. Table A1 summarizes the five errors detected by patients, which included no clinically important errors.
Of the clinically important prescribing errors identified at audit, 21.9% (n = 118) had been detected, of which seven had an incident form. Table 2 presents a summary of the rates at which prescribing errors were identified at audit, detected by staff and reported to the incident systems, by hospital. Figure 1a shows the distribution of prescribing errors identified, detected and reported and Fig. 1b shows this information for clinically important prescribing errors.
(Enlarge Image)
Figure 1.
Distribution of (a) prescribing errors observed by researchers, and detected and reported by clinical staff; (b) clinically important prescribing errors observed by researchers, and detected and reported by clinical staff.
Rates of Clinically Important Prescribing Errors Identified at Audit, Detected by Staff and Reported for Each Hospital
For the 3291 patient admissions reviewed, 539 had clinically important prescribing errors, a rate of 16.4/100 patient admissions. Of these, 118 were detected by staff, a rate of 3.6/100 admissions and the rate at which these were reported via the incident reporting systems was 0.21/100 admissions (n = 7).
We examined each hospital's data. At Hospital A, 8621 prescribing errors were identified at audit for 1948 patient admissions, a rate of 4.43/100 admissions. At Hospital B, 1530 prescribing errors for 1343 admissions (1.14/100) were found at audit. However, the number of reported incidents for Hospital A was 0.34/1000 prescribing errors and for Hospital B 3.04/1000 prescribing errors (Table 2). Thus, Hospital A with the higher overall prescribing error rate had an incident reporting rate significantly lower than Hospital B (P < 0.0001).
Comparison of Medication Administration Errors Observed With Those Reported to the Hospitals' Incident Systems
The direct observational study of 7451 drug administration yielded 10 955 medication administration errors. Of these, the vast majority (79%) were procedural errors (e.g. failing to check a patient's identification prior to drug administration). One or more clinical errors occurred in 27.4% (n = 2043; 95% CI: 26.4–28.4%) of drugs administered. 10.2% (n = 209; 95% CI: 8.9–11.5%) of all drug administrations involved errors which were rated as clinically important.
Of the 10 955 administration errors observed none had an incident report. Table A3 provides examples of clinically important medication administration errors observed. We had no information about administration errors detected by staff. During the period of the observational study, 173 medication administration errors, involving administrations not observed by the research staff, were reported to the hospitals' incident systems.
