Abstract :

This article discusses the efforts to improve the reporting and analysis of medication errors in a tertiary care hospital. It highlights the underreporting of medication errors and presents the steps taken to address this issue, including training sessions, online incident reporting, and the involvement of a clinical pharmacologist. The results show a significant increase in error identification and emphasize the importance of staff’s perception towards reporting errors in enhancing patient safety.

Organization Profile

Dr. Sharan Shivraj Patil, the founder and chairman of SPARSH Hospitals, established the group’s first hospital 16 years ago. The group operates five centers across Bangalore, Davangere, and Hassan, with over 1500 beds. Our values of faith, hope, and love serve as guiding principles at SPARSH Hospital. We firmly believe that world-class healthcare should be accessible to all, irrespective of their affluence.

SPARSH Hospital gained global recognition when a team of doctors, led by Dr Sharan Patil, successfully performed a 27-hour surgery on Lakshmi Tatma, an anischiopagus conjoined twin with eight limbs. In 2010, SPARSH Hospital became the first standalone orthopaedic hospital in the country to receive NABH accreditation, and other units within the group have obtained either accreditation or certification. DNB recognizes SPARSH Hospital for training in various broad specialties, including orthopaedics, anesthesia, radiology, cardiology, general medicine, and general surgery. While SPARSH Hospital is renowned for its world-class orthopedic care, it has expanded to become a multi-specialty hospital offering comprehensive patient care services across various departments. These include neurosciences, cardiology, urology, surgical gastroenterology, medical and surgical oncology, multi-organ transplantation, trauma and emergency care, plastic and reconstructive surgery, pediatrics, gynaecology, critical care, endocrinology, ENT, dental sciences, radiology, and organ transplantation.

Sparsh Hospital, located in Yeshwanthpur, Bengaluru, is a 250-bedded super speciality hospital established in 2015. The hospital has achieved NABH accreditation, demonstrating its commitment to quality and patient care.

Introduction

A medication error refers to any avoidable occurrence that could result in inappropriate medication use or harm to a patient while the medication is controlled by a healthcare professional, patient, or consumer. These errors can have serious consequences, leading to increased morbidity and mortality rates if left unaddressed. Additionally, medication errors contribute to higher healthcare costs for patients. Several published studies have highlighted the impact of medication errors on healthcare systems.

For instance, research in Sweden indicates that 5–10% of hospital admissions and 3% of reported deaths are attributed to medication errors. Similarly, a study conducted in Canada revealed that approximately 50% of incidents in primary healthcare settings are linked to medication errors.

During the analysis of medication error trends in the past two years, it was noticed that there was a significant level of underreporting of medication errors within the hospital setting. In 2019, 25 medication errors were officially reported; in 2020, the number of reported medication errors decreased to 11.

A process mapping was conducted to assess the existing system for reporting medication errors. These errors were:

• Medication errors were captured through Incident report forms, which doctors and nursing staff raised upon identifying mistakes.
• Documentation errors were identified during live chart audits conducted by the quality team.
• Most reported errors were administration errors, with rare indenting and dispensing errors.
• A Fish Bone analysis determined the causes of underreporting medication errors.
• The main contributing factors to underreporting were related to people, including a lack of awareness about the importance of reporting near misses, fear, and negative perceptions towards incident reporting.
• Difficulties accessing and completing incident reporting forms were also identified as factors leading to poor reporting.

Additionally, the absence of a dedicated and competent person to identify errors such as wrong strength, wrong formulation, and wrong rate was recognized as contributing to the underreporting of medication errors.

Several measures were implemented to address the underreporting of medication errors. Re-training sessions were organized for nurses, doctors, and pharmacists to enhance their knowledge and understanding of medication errors. An online incident reporting form was introduced to facilitate quick and efficient reporting of incidents. Additionally, a simple form specifically designed to capture dispensing errors was implemented.

To further improve error identification, a clinical pharmacologist (CP) was included as part of the daily rounds. Educational materials focusing on medication error incidents, particularly prescription errors, were circulated among clinicians to raise awareness and promote a culture of reporting and learning from mistakes. These initiatives aimed to create a supportive environment where healthcare professionals felt encouraged and equipped to report medication errors, ultimately improving patient safety and reducing the occurrence of preventable harm.

Outcomes

To maintain the improvements, the following steps were taken:

• Strengthening Medication Error Mitigation: Daily rounds by the clinical pharmacologist and new data-capturing formats led to the identification of 24 errors in the ICU (Jun-Aug’21), compared to 12 errors in Jan-Apr’21.
• Replication of Mitigation Activities: Mitigation efforts were expanded to all hospital areas, providing revised data capture forms and accessible incident reporting links to enhance staff reporting of medication errors.

Enhancing Patient Safety: Identifying and Addressing Medication Errors in 2021

• Medication errors were categorized into A to I categories based on the level of harm, using the NCCMERP* guidelines.
• In 2021, 1,573 medication errors were identified among 8,706 inpatients.
• Among these errors, 1,396 (89%) were classified as category A errors, indicating their potential to cause harm.
• Notably, this category A errors were identified and addressed before they could reach the patients.
• This underscores the significance of improving the staff’s perception towards reporting errors in enhancing patient safety.