PS-048 Detecting medication errors in a tertiary hospital using dextrose 50% as trigger tool

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Abstract

Background

To prevent medication errors and reduce the risks of harm, organisations need tools to detect them as well as to develop key performance indicators (KPI) to identify adverse drug events (ADEs) and to determine whether ADEs are reduced over time as a result of improvement efforts. The Institute for Healthcare Improvement (IHI) global trigger tool for ADEs provides an easy to use method for accurately identifying ADEs and measuring the rate of ADEs over time. A study comparing focused trigger tools and traditional reporting to identify medical related problems showed that 107 of ADEs were identified using trigger tools while only 3.7% of ADEs were identified by using traditional voluntary reporting methods. Another study carried out to evaluate the incidence of ADEs in hospitals utilising 3 methods of detecting ADRs, revealed that the IHI global trigger tools found at least 10 times more confirmed serious events than these other methods.

Purpose

To identify and measure the incidence of hypoglycaemia and hyperkalaemia in a tertiary hospital due to medication errors using dextrose 50% as the trigger tool.

Material and methods

The study was conducted over a period of 1 month. A daily report was generated using a reporting system for all dextrose 50% that had been removed from the automated dispensing cabinets. The report was used to identify patients, and then each patient case was reviewed to find the indication for usage. If the case was recognised as a medication error, then a classification for the type and severity was established using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) categories. The study was approved by the institutional review board.

Results

The total reviewed charts was 184. The indications to use dextrose 50% were as follows: 92 cases for hypoglycaemia, 59 cases for hyperkalaemia and 33 deviations from hospital policy. The dextrose 50% was used due to medication errors in 49 cases of hypoglycaemia and 16 cases of hyperkalaemia.

Conclusion

This study demonstrated the usefulness of trigger tools such as a KPI in order to evaluate the efficiency of the safety systems that are used in hospitals.

Conclusion

No conflict of interest

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