Medication Discrepancy‐Related Medication Safety Incidents in Surgical Patients: A Register Study Based on Medication Safety Incident Reports
Saralotta Vähälä, Miia Tiihonen, Esa Jämsen, Ville Valkonen, Terhi ToivoABSTRACT
Background and Aims
Surgical patients are at high risk of experiencing medication errors, particularly those related to the lack of accurate medication history. This study aimed to determine the number and the nature of reported medication safety incidents in surgical patients in a Finnish University Hospital.
Methods
In this retrospective study, the medication safety incidents ( n = 902) reported in 7 surgical units of a Finnish University Hospital during 2021–2022 were quantitatively analyzed. Incident reports concerning medication discrepancy errors (i.e.a mismatch between the documented medication list and the intended medication regimen) were further assessed with an inductive and data‐driven analysis based on their free text sections.
Results
There was a total of 902 incidents. Of these, 70.6% were classified as patient involved incidents and 29.4% near misses. The most common incidents were administration errors (45.8%, n = 413) and prescribing errors (20.7%, n = 187). The most reported medicines were antithrombotics (24.1%, n = 140) and opioids (14.3%, n = 83). Approximately (39% n = 350) were related to errors in up‐to‐date medication information, such as in the documentation of the patient's electronic medication list (46.0%, n = 161) and the lack of medication reconciliation (30.3%, n = 106). Most of these discrepancy incidents caused no clinical consequences to the patient (69.9%), while some resulted in treatment delays (7.7%), psychological/cognitive symptoms (6.4%) and cardiorespiratory symptoms (5.1%). The majority of the incidents did not affect the duration of hospitalization (83.3%) but some required extra work or monitoring (9.8%).
Conclusion
Medication discrepancy‐related incidents accounted for approximately 39% of the medication safety incidents reported from the surgical units. Improving adherence to electronic medication list protocols, communication among care personnel, and clarity of professional responsibilities may support medication safety in surgical care.