Medication Error & Near Miss Reporting

Basic Medication Safety (BMS) Certification Course

King Saud bin Abdulaziz University for Health Sciences
Ministry of National Guard – Health Affairs
1
 Learning Objectives
• Explain the reasons for reporting medication safety
incidents
• State the types of reportable medication safety
incidents
• Submit relevant information when reporting
medication safety incidents
• Recall the local medication errors / near misses data
• Explain the mistake lesson learning cycle
 Why Report?
• Ethical / medico-legal obligation
• Help identify hazards and risks in the system
• Sharing and learning
REPORTS
 What to Report?

Medication
Safety
Incident

Potential Adverse Drug

Adverse Drug Event
Event (PADE) (ADE)

Adverse Drug
Hazardous Reaction Medication
Near Miss
Condition Error
(ADR)

Source: AMNCH Tallaght: Medication Safety Incident Reporting Policy DTC4/2002

 What Information to Report?
• JUST THE FACTS - include a factual description of what
happened, how it happened, why it happened and the patient
outcome
• Include names of products if the event involves a problem
with labeling or packaging
• Include any additional patient monitoring or testing
performed or medications administered as a result of the
event
How to Report?
How to Report?
8
What Happens to the Report?
 What Happens to Me?
MNG-HA adopts a “JUST CULTURE” approach in
error reporting:
• Creating an open, fair, and just culture
• Creating a learning culture
• Designing safe systems
• Managing behavioral choices
 Number of Medication Error at KAMC - Riyadh
from Jan 2013 – Nov 2015
300 MSP Allergy
Awareness Campaign 282
Pharmacy Allergy 277
Awareness Campaign 262 264
258
249
250 240 266
218
216
200 Cefuroxime allergy 205 217 187 206 185
179 199
incident 188
182
175
150
129 140 146 SRS
112 112 126 Campaign/
106 100 SRS Reporting
100 89 campaign/ Harm
112
Good Catch Ramadan
81 91 Program &
82 Hajj 88
73 Summer
Holiday Holiday
50
MERS-CoV
Outbreak
0
 Medication Error and Near Miss:
Harm Category
1000
January – December 2014: Central Region
863
900

800
Total number =
2079
700

600
493
500
409
400

300

200
133
86 71
100
22 2
0
N/S A-Potential to B-Near Miss-Error C-Error reached D-Required E-Temporary F-Temporary Not Applicable
cause did not reach the individual-No monitoring to Harm-Required Harm-Required
Harm/Damage individual Harm/Damage confirm No intervention hospitalization
Harm/Damage
What Did We Learn from the Data?

Error / Near
Miss

Monitoring of
implementation Recognize Error /
Near Miss

System-wide
corrective / Report Error /
preventive action Near Miss

Analyze Error /
Near Miss
Overall Lessons Learned