Omitting medicines is the medication administration error (MAE) most commonly associated with death in England and Wales, accounting for almost a third of MAEs.
The figure is reported in a study published in the journal Research in Social and Administrative Pharmacy, which looked at MAEs occurring in acute care trusts in 2007-2016 (n=517,384) according to the National Reporting and Learning System for England and Wales. Incidents reported as resulting in death (n=229) were analysed.
The data showed that MAEs most commonly occurred on noncritical care wards (66.4%) and in patients aged over 75 years (41.5%). The most common error category was omitted medicine (31.4%), followed by wrong dose or strength (10.5%).
The most common drug groups involved were cardiovascular agents (20.1%, n=46). Of these, 26 were parenteral anticoagulants, 6 were oral anticoagulants and 6 were sympathomimetics. The second most common were drugs of the central nervous system (10.0%), of which analgesics were most common.
Commenting on the findings, the authors say, “each death caused by medication error is one death too many”.
“More knowledge and competence in handling drugs and administration of drugs should be provided to all health professionals, especially nurses, as they are usually the final step in the medication use process,” they write.