Investigation to increase safety and minimize mistakes in connection with handling of medicine for patients in the counties of South Jutland and Frederiksborg.

Doses that are too low or too high. Medicine that is given too early, too late or incorrectly. There are many ways in which medicine can be handled incorrectly and which lead to mistakes when patients are given medication at the hospitals throughout Denmark.

In fact, mistakes in connection with administration of medicine to patients accounted for more than a third of the events that were registered in the national database for adverse events.

The hospitals in the counties of South Jutland and Frederiksborg have decided to increase safety in connection with administration of medicine by reducing the possibilities of mistakes. This will be done by looking at the circumstances that lead to medication mistakes.

Therefore, an investigation of the circumstances that may lead to mistakes in connection with administration of medicine was completed in the two counties last year. 

"Our experience has shown that it is not enough just to change medicine tables or procedures when we want to eliminate medication mistakes. We need some tools to help us make more exact analyses of the adverse events so that we can address the problems effectively", says quality manager at the quality section of the county of South Jutland, Birgit Viskum.

Focus on the circumstances

FORCE Technology has carried out the investigation on the basis of data material and observations at a hospital in the county of South Jutland. The results have been discussed regularly with the quality section of the county of South Jutland and the Risk Unit, FoQUS, county of Frederiksborg.

"The aim has been to dig one step deeper into the analysis of the mistakes. Therefore, we have also taken a closer look at the circumstances under which the mistakes are made. For example, we know that factors such as stress, interruptions during distribution and administration of medicine as well as poor communication between staff members are sources of error. But we have to examine what causes stress, interruptions and poor communication. In other words, we have to study the event itself and the circumstances under which the mistake was made and how it was discovered in order to draw a full picture that can help us effectively prevent such mistakes", says Thomas Koester from FORCE Technology.

Different sources of error

The investigation points out a number of areas that may be successfully addressed in order to increase safety during handling of medicine. For example, it is very important how the medicine rooms at the hospitals are laid out and equipped. A practical, well thought-out and user-friendly layout of the rooms can reduce the number of mistakes. Recommendations are being prepared for these conditions with respect to layout of medicine rooms as well as the location of medicine at the hospitals in South Jutland.

Work pressure and stressful situations lead to mistakes. The many interruptions experienced by the individual staff member during the work is not only disruptive, but it also puts pressure on the staff member's safety routines and memory. 

"We have to focus more on finding tools that may be helpful for the nursing staff in their everyday work. These tools should also be able to relieve the pressure on their memory and perhaps also involve the individual patient more in the safety aspect of medicine administration. For example, it is possible to reduce mistakes by giving the patient his/her pills one by one and explaining which type of pill is given and for what. This makes it possible for the patient to comment on the medicine if he/she is given medicine that is not usually given", says Birgit Viskum.

The investigation has already given rise to a number of recommendations as to how medicine mistakes can be minimized and patient safety increased at the hospitals in the two counties. These recommendations have also been adopted by the Danish National Board of Health.

The idea is also for the investigation to be followed up by a large project, which will examine the medicine mistakes in more detail. The plan is then for methods and results to be used to review types of events within other areas at the hospitals – for example handling of patient records and test results.