Abstract
Background Medication incidents (MIs) account for 11.3 % of all reported patient-safety incidents in England and Wales. Approximately one-third of inpatients are prescribed an antibiotic at some point during their hospital stay. The WHO has identified incident reporting as one solution to reduce the recurrence of adverse incidents. Objectives The aim of this study was to determine the number and nature of reported antibiotic-associated MIs occurring in inpatients and to use defined daily doses (DDDs) to calculate the incident rate for the antibiotics most commonly associated with MIs at each hospital. Setting Two UK acute NHS teaching hospitals. Methods Retrospective quantitative analysis was performed on antibiotic-associated MIs reported to the risk management system over a 2-year period. Quality-assurance measures were undertaken before analysis. The study was approved by the clinical audit departments at both hospitals. Drug consumption data from each hospital were used to calculate the DDD for each antibiotic. Main outcome measures The number of antibiotic-related MIs reported and the incident rate for the 10 antibiotics most commonly associated with MIs at each hospital. Results Healthcare staff submitted 6,756 reports, of which 885 (13.1 %) included antibiotics. This resulted in a total of 959 MIs. Most MIs occurred during prescribing (42.4 %, n = 407) and administration (40.0 %, n = 384) stages. Most common types of MIs were omission/delay (26.3 %, n = 252), and dose/frequency (17.9 %, n = 172). Penicillins (34.5 %, n = 331) and aminoglycosides (16.6 %, n = 159) were the most frequently reported groups with co-amoxiclav (16.8 %, n = 161) and gentamicin (14.1 %, n = 135) the most frequently reported drugs. Using DDDs to assess the incident rate showed that cefotaxime (105.4/10,000 DDDs), gentamicin (25.7/10,000 DDDs) and vancomycin (23.7/10,000 DDDs) had the highest rates. Conclusions This study highlights that detailed analysis of data from reports is essential in understanding MIs and developing strategies to prevent their recurrence. Using DDDs in the analysis of MIs allowed determination of an incident rate providing more useful information than the absolute numbers alone. It also highlighted the disproportionate risk associated with less commonly prescribed antibiotics not identified using MI reporting rates alone.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Williams DJP. Medication errors. J R Coll Physicians Edinb. 2007;37:343–6.
National Patient Safety Agency. National reporting and learning system quarterly data workbook up to December 2011. National Reporting and Learning System 2012.
National Patient Safety Agency (NPSA) Safe medication practice team. Safety in Doses, Medication safety incidents in the NHS. National Reporting and Learning System 2007.
Rothschild J, Churchill W, Erickson A, Munz K, Schuur J, Salzberg C, et al. Medication errors recovered by emergency department pharmacists. Ann Emerg Med. 2010;55(6):513–21.
Ross L, Wallace J, Paton J, Stephenson T. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83:492–7.
Lewis P, Dornan T, Taylor D, Tully M, Wass V, Ashcroft D. Prevalence, incidence and nature of prescribing errors in hospital inpatients, a systematic review. Drug Saf. 2009;32(5):379–89.
Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ. 2009;338:b814.
Leape L, Abookire S. WHO draft guidelines for adverse event reporting and learning systems: From information to action. Geneva: WHO World Alliance for Patient Safety; 2005.
Dean B, Lawson W, Jacklin A, Rogers T, Azadian B, Holmes A. The use of serial point prevalence studies to investigate antiinfective prescribing. Int J Pharm Pract. 2002;10:121–5.
National Patient Safety Agency (NPSA) Safe medication practice team. Safety in Doses, Improving the use of medicines in the NHS. National Reporting and Learning System 2009.
WHO Collaborating Centre for Drug Statistics Methodology and Norwegian Institute of Public Health. http://www.whocc.no/ddd/definition_and_general_considera. Accessed 17 August 2011.
Monnet DL. ABC Calc.—Antibiotic Consumption Calculator [Microsoft® Excel application]. Version 3.1. Copenhagen (Denmark): Statens Serum Institut; 2006.
Ashcroft D, Cooke J. Retrospective analysis of medication incidents reported using an on-line reporting system. Pharm World Sci. 2006;28:359–65.
Picone D, Titler M, Dochterman J, Shever L, Kim T, Abramowitz P, et al. Predictors of medication errors among elderly hospitalized patients. Am J Med Qual. 2008;23(2):115–27.
National Patient Safety Agency. Rapid Response Report NPSA/2010/RRR009: Reducing harm from omitted and delayed medicines in hospital: Supporting Information. National Reporting and Learning System 2010.
Thomas M, Schultz T, Hannaford N, Runciman W. Mapping the limits of safety reporting systems in health care–what lessons can we actually learn? Med J Aust. 2011;194(12):635–9.
National Patient Safety Agency. Review of patient safety in children and young people. National Reporting and Learning System 2009.
Alrwisan A, Ross J, Williams D. Medication incidents reported to an online incident reporting system. Eur J Clin Pharmacol. 2011;67:527–32.
Kingston M, Evans S, Smith B, Berry J. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust. 2004;181(1):36–9.
Gavaza P, Brown C, Lawson K, Rascati K, Wilson J, Steinhardt M. Influence of attitudes on pharmacists’ intention to report serious adverse drug events to the food and drug administration. Br J Clin Pharmacol. 2011;72(1):143–52.
Olsen S, Neale G, Schwab K, Psaila B, Patel T, Chapman E, et al. Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Qual Saf Health Care. 2007;16:40–4.
Cullen D, Bates D, Small S, Cooper J, Nemeskal A, Leape L. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10):541–8.
Field T, Gurwitz J, Harrold L, Rothschild J, Debellis K, Seger A, et al. Strategies for detecting adverse drug events among older persons in the ambulatory setting. J Am Med Inform Assoc. 2004;11(6):492–8.
Ghaleb M, Barber N, Franklin B, Wong I. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child. 2010;95(2):113–8.
Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010;105(1):69–75.
Acknowledgments
The authors appreciate the invaluable help provided by Alice Oborne in accessing the data needed from hospital B and by Moira Talpaert in calculating the DDDs at hospital A.
Funding
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. However, Anas Hamad received a scholarship from Hamad Medical Corporation, Qatar, to undertake this postgraduate research.
Conflicts of interest
The authors declare that they have no conflicts of interest to disclose.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Hamad, A., Cavell, G., Wade, P. et al. Risk of medication safety incidents with antibiotic use measured by defined daily doses. Int J Clin Pharm 35, 772–779 (2013). https://doi.org/10.1007/s11096-013-9805-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11096-013-9805-9