[Descriptive analysis of medication errors notified by Primary Health Care: Learning from errors].

Abstract

INTRODUCTION AND OBJECTIVES\nAim of this study is to determine the setting, causes, and the harm of medication errors (ME) which are notified by Primary Health Care.\n\n\nMATERIAL AND METHODS\nSetting: Primary Care Regional Health Service of Madrid. 2016.\n\n\nDESIGN\nDescriptive and cross-sectional study.\n\n\nPARTICIPANTS\nAll ME (1,839) which were notified by Primary Care Centres by notification system of safety incidents between January 1st 2016 and November 17th 2016.\n\n\nMAIN MEASUREMENTS\nSetting, real harm, potential harm, and cause of error. These items were classified by one researcher. Concordance was checked with another researcher.\n\n\nRESULTS\nJust under half (47%) (95% CI: 44.8%-49.3%) of ME occurred in Primary Care Centre, 26.5% (95% CI: 24.5%-28.6%) of ME were patient medication errors, and 27.5% (95% CI: 24.1%-30.8%) of ME were potential severe harm errors. Prescribing errors were the cause of most ME in Primary Care Centre [27.4% (95% CI: 24.4%-30.4%)]. Communication between patients and doctors were the cause of most patient medication errors [66% (95% CI: 61.8%-70.2%)]. Patient mistakes and forgetfulness were also causes of patient medication errors.\n\n\nCONCLUSIONS\nHalf of all mediation errors hppened at Primary Care Center while one quarter of them were patient medication errors. One quarter of all ME were potential severe harm errors. The main causes were prescribing errors, failure of communication between patients and doctors, and patient mistakes and forgetfulness. Prescribing aid systems, communication improvements and patients aids should be implemented.