Enhancing medication safety: Description of characteristics of medication errors and effectiveness of quality improvement strategies

Medication errors (MEs) pose a significant threat to patient morbidity, prompting an urgent need to explore the impact of various risk reduction strategies. The goals of this study were to 1) review reporting rates, types, and characteristics of MEs at a single institution from 2015 to 2023 and 2) review quality improvement strategies using the hierarchy of intervention effectiveness framework devised by the Institute for Safe Medication Practices (ISPM). 1 Between 2015 and 2023, all self-reported MEs in all anesthetizing locations in the academic medical center were collected. The primary outcome is the rate of ME reporting per 10,000 medication administrations. Descriptive analyses were implemented to summarize the characteristics of medication errors. Trends over time in MEs were evaluated using a control chart (p-chart). 114 MEs s were reported in 4,525,405 medication administrations (0.252 errors per 10,000 medication administrations; 95 % CI: 0.208, 0.303). The most common ME types were incorrect dose ( n = 62, 54.4 %), incorrect medication ( n = 27, 24 %), and incorrect time ( n = 22, 19 %). The most common medication types were antiemetics ( n = 21, 18 %), opioid analgesics ( n = 20, 18 %), other analgesics (n = 20, 18 %), and antibiotics ( n = 15, 13 %). MEs were most commonly conducted by residents ( n = 50, 44 %), attendings ( n = 28, 25 %), and fellows (n = 15, 13 %). 38 ISMP risk-reduction strategies were implemented to respond to 59 violations of “Rights of Medication Administration”. 2 This study describes the rates over time and characteristics of self-reported MEs at a single institution and summarizes quality improvement strategies. Despite advances in medicine, technology, and emerging evidence-based practices, challenges persist with the effectiveness of the current ME risk-reduction strategies. Several factors contribute to MEs, including system complexities, poor integration of existing workflows, technological issues, a large influx of trainees, and the need for continuous training. • SBAR = Situation-Background-Assessment-Recommendation. • IPASS = Illness severity, Patient information, Action list, Situation awareness and contingency plans, Synthesis by receiver. • The NetLearning Management System = Educational system used to implement and track courses and competencies.