Benchmarking of medication incidents reporting and medication error rates in a JCI accredited university teaching hospital at a GCC country

May Hassan ElLithy; Hager Salah; Lamyaa Samir Abdelghani; Walid Assar; Martin Corbally

doi:10.1016/j.jsps.2023.101726

Benchmarking of medication incidents reporting and medication error rates in a JCI accredited university teaching hospital at a GCC country

Saudi Pharm J. 2023 Sep;31(9):101726. doi: 10.1016/j.jsps.2023.101726. Epub 2023 Aug 5.

Authors

May Hassan ElLithy¹, Hager Salah², Lamyaa Samir Abdelghani³, Walid Assar^{4

5}, Martin Corbally⁶

Affiliations

¹ Head Pharmaceutical Quality Services Department, King Hamad University Hospital, Bahrain, Founder of QuaMay (for Hospital Quality Improvement & Patient Safety Consultation, Training, and Education services), UAE.
² Pharmaceutical Services Department, Research Coordinator -AMS Pharmacist, King Hamad University Hospital, Bahrain.
³ Head Pharmaceutical Services Department, King Hamad University Hospital, Bahrain.
⁴ Drug and Therapeutic chairman, King Hamad University Hospital, Bahrain.
⁵ Cardiology, Al-Azhar University, Egypt.
⁶ Consultant Pediatrics Surgeon, King Hamad University Hospital, Bahrain.

Abstract

Introduction: The benchmarking for medication incidents rate is not regarded as a recognized key performance measure or indicator in national or international organizations. The absence of benchmarking the medication incidents results in the loss of a self-governing perception of how well we performed compared to other peers.

Methodology and settings: This 600-bed tertiary, Joint Commission International (JCI) accredited hospital retrospective analysis looked at all medication management-related events from January-2018 to December-2021. The study design follows descriptive, cross-sectional, retrospective prevalence research.

Results: The rate of medication incidents that resulted in harm declined from Q3-2019 to Q4-2021. A significant increase in Pharmacy interventions/clarifications was recorded. Additionally, a significant increase in incidents reported with no-harm coupled with a significant reduction in incidences of serious events from 2019 to 2020. Finally, no-harm events were significantly reduced from 2020 to 2021.

Discussion: The Pharmacy's study analyzed every medication incident documented from 2019 to 2021. 99.7% of reported incidents were classified as no-harm (near misses). There was an exponential decrease from Q1-2020 to Q1-202. A significant increase in incidents fell in the category of (near misses) with no-harm and a significant reduction in serious events. Pharmacy interventions/clarifications saw a massive increase and impact from Q3-2018 to Q2-2019, compared to the same period in 2018. By preventing medical incidents, benchmarking, and analyzing incidents and the reporting system, the use of information technology could dramatically reduce the rate of drug incidents.

Conclusion: This study found that benchmarking medication incidents is valuable, as it can help identify areas where improvements can be made, implement strategies to improve safety, and track progress over time. The benchmark was recommended to be below 100 incidents for every 10,000 prescriptions/orders processed, and for E-I categories, below one incident for every 10,000 prescriptions/orders processed. This will help develop a worldwide standard with an absolved culture with non-punitive consequences.

Keywords: Benchmarking; Error; Events; Incident rate; Medication data; Medication incidents; Pharmacy; Reporting.