4CPS-154 Medication errors at discharge: severity and root causes. What do our doctors think?

<h3>Background and Importance</h3> Transition points between Community and Hospital are known to generate medication errors (MEs). Medication reconciliation is a robust action to intercept MEs. The MEDISIS care pathway secures the medication management of hospitalised patients aged ≥ 65. It involves medication reconciliations at admission, during transfers, and at discharge. <h3>Aim and Objectives</h3> The aim of this study is to assess the potential severity of MEs at discharge and to analyse their root causes. <h3>Material and Methods</h3> The study is conducted in the medicine and surgery departments over 2 months for MEDISIS patients. Potential severity is assessed by a physician/pharmacist pair using the HAS scale on the severity of medication errors. Root causes are determined interviewing physicians for each ME. <h3>Results</h3> Over 2 months, 51 MEs were intercepted for 107 reconciled patients at discharge, averaging 0.5 ME per patient. Of these, 39 were corrected (76%). Regarding potential severity, according to the pharmacist, 73% of MEs were minor (37), 20% significant (10), and 8% major (4); none were critical or catastrophic. According to the physician, nearly half of the MEs (52%, 26) had minor potential severity, 46% were significant (23), and 4% catastrophic (2). About the causes, each ME was judged to be multifactorial. The three most frequently mentioned causes were: attention errors (32, 63%), task interruptions (31, 61%), and writing the discharge prescription under stress or in urgent situations (26, 51%). Number of medications (4, 8%), lack of knowledge of the medications (4, 8%), and associated risks (3,6%) were the three least mentioned causes. One-quarter (13) of the MEs corresponded to those intercepted at admission and persisting until discharge. <h3>Conclusion and Relevance</h3> The study highlights the impact of disorganisation during hospital discharge on the occurrence of MEs. Although most MEs are labelled as minor, the presence of potentially major or catastrophic MEs draws attention to the importance of a secure discharge process. Implementing a care pathway that includes medication reconciliation at each transition point is an effective way to limit adverse events related to health products. <h3>References and/or Acknowledgements</h3> <h3>Conflict of Interest</h3> No conflict of interest