Analysis of Medication Errors and Adverse Event Reporting from the Medication Risk Reporting Program at Buriram Hospital

Abstract

Background: Medication errors (ME) may cause or lead to inappropriate drug use or harmful to patients. Adverse drug events (ADE) are illnesses that occur during treatment and are related to a drug. Analysis of incident reports reveals the volume of problems and the level of severity that should be addressed and prevented.

Objectives: To analyze quantitative data of ME and ADE reports, evaluate ADEs as preventable events or not, and evaluate the performance or screening system for ME prevention at Buriram Hospital.

Method: This was retrospective descriptive research. The population was the medication incidence report data of Buriram Hospital which were reported through the National Reporting and Learning System for Clinical Risk Incidences and Adverse Events in Thailand (NRLS) during 1 October 2018 – 30 September 2021. Quantitative data of ME and ADE reports were analyzed by the NRLS system and evaluate whether it is a preventable event or not according to the Schumock and Thornton criteria tool.

Results: 8,991 reports were analyzed, consisting of ME 8,719 reports (96.97%) and ADE 273 reports (3.03%). The harm level with the highest number of reports was harm B 6,265 reports (69.68%), followed by harm E to I in 202 reports (2.25%). 53 ADE incidents were considered preventable. 103 incidents were ADEs from high alert drugs . 2,194 reports (95.73%) were harm B prescribing error. The screening system was able to prevent patients from receiving medication with a history of allergic reaction in 200 reports and also prevent errors in administering high alert drugs in 63 reports.

Conclusions: The majority of medication risk incidence reports at Buriram Hospital which reported through the NRLS system were pre-dispensing errors and harm B severity levels. System for prevention of repeated drug allergy and cross-professional checking specified by the hospital could prevent prescribing errors from reaching to patient. However, analysis of ADE reports found a number of preventable events.