255Medication Errors- An Unidentified Silent Killer- Jack the Ripper of Our Age

Abstract

Background: Health Information and Quality Authority's (HIQA) Guidance for health and social care providers - Principles of good practice in Medication reconciliation-reports that in Ireland the medication incidents most commonly reported to the Clinical Indemnity Scheme in 2012 were medication reconciliation incidents. More than 40% of medication errors occur due to inadequate reconciliation in handoffs during admission, transfer, and discharge of patients. 20% are believed to result in harm and would have been averted if effective medication reconciliation processes were in place. An audit to assess the medication errors and degree of compliance with medication reconciliation within 24 hours of admission and transfer of patients in University Hospital Limerick (UHL) was carried out in 2015. As a result, medication errors were identified as occurring in 76% of admissions and only 44% of medication reconciliation was performed within 24 hours of admission. Recommendations were made and a change process implemented. Methods: 62 patients were randomly selected and re-audited to assess the degree of compliance with the medication reconciliation recommendations and the change process. Results: Medication reconciliation was performed only in 43 (69%) and not in 19. Reconciliation was performed within 24 hours in 24 patients (55%); within 48 hours in 8 patients; within 72 hours in 7 patients. Further reconciliation errors were found within the final step of the medication reconciliation process - discharge prescribing errors. Most of the errors were highlighted by the community pharmacists and patients own General Practitioners. Unintentional prescription of stopped medications; error in the dose, frequency or formulation and omission of active medications were the most common error types. Conclusion: There is a need to implement an electronic medication reconciliation tool as part of a planned e-prescribing initiative at UHL which also includes discharge medication reconciliation to support medication optimization post-hospitalization.