Medication errors - A systematic analysis of CIRS-AINS reports

Brinkrolf P, Prien T, Van Aken H

Zusammenfassung

Avoidance of medication errors is a relevant factor in improving patient safety. Since such errors are most often due to risky behaviour, we undertook an analysis of the reports in the Critical Incident Reporting System (CIRS-AINS). 235 reports of medication-associated incidents or errors were examined for type of error and the situation presenting. In particular, the attendant circumstances reported, were noted. With respect to work areas, an almost equal distribution of errors was found for induction of anaesthesia (23%), anaesthesia during surgery (29%), the intensive care unit (21%) and other work areas (22%). 45% of the errors occurred during preparation of the medication and 37% during its application. 5% of the errors were associated with delivery & storage. All 235 CIRS-reports were evaluated for known risk factors of medication errors. "Look-alikes" (similar medication packaging, ampoules or labels) were involved in almost one-quarter of the errors (53 reported). In this context it is of interest to know whether the introduction by the DIVI in 2010 of labelling standards according to ISO met its postulated aim of increasing medication safety. Critical incident reporting systems do not enable evaluation of error frequencies. However, the analysis of incident reports using non-ISO-compliant labels identified in particular confusion between drugs of different groups. In contrast, with standardised labels most mistakes occurred between medications within the same group of substances. The latter errors presumably have less serious consequences than confusing drugs with completely different actions. It is worth noting that, in most reports analysed, the mis-application of medication had already taken place (68%). This is in contrast with the intention of CIRS, viz avoiding errors by analysing reports of critical incidents.