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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

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 Event (PADE)

Near Miss Hazardous Condition

Adverse Drug Event

(ADE)

Adverse Drug Reaction

(ADR)

Medication Error

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?

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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

81

112

112

129

106

82

100

73

89

91

112

140

218

205

258

217

262

179

146

175

187

126

188

249

199

240

206

264

266

282

182

185

88

216

277

0

50

100

150

200

250

300

Cefuroxime allergy incident

Pharmacy Allergy Awareness Campaign

SRS campaign/ Good Catch

Program Ramadan

& Summer Holiday

Hajj Holiday

SRS Campaign/Reporting

Harm

MSP Allergy Awareness Campaign

MERS-CoV Outbreak

Number of Medication Error at KAMC - Riyadh from Jan 2013 – Nov 2015

86

409

863

493

133

22 2

71

0

100

200

300

400

500

600

700

800

900

1000

N/S A-Potential tocause

Harm/Damage

B-Near Miss-Errordid not reach the

individual

C-Error reachedindividual-No

Harm/Damage

D-Requiredmonitoring to

confirm NoHarm/Damage

E-TemporaryHarm-Required

intervention

F-TemporaryHarm-Requiredhospitalization

Not Applicable

Medication Error and Near Miss: Harm Category

Total number = 2079

January – December 2014: Central Region

Error / Near Miss

Recognize Error / Near Miss

Report Error / Near Miss

Analyze Error / Near Miss

System-wide corrective /

preventive action

Monitoring of implementation

What Did We Learn from the Data?

Overall Lessons Learned