Exploring the role of guidelines in contributing to medication errors: A descriptive analysis of national patient safety incident data (2 February 2024)

Summary

Clinical guidelines can contribute to medication errors but there is no overall understanding of how and where these occur. This study aimed to identify guideline-related medication errors reported via a national incident reporting system, and describe types of error, stages of medication use, guidelines, drugs, specialties and clinical locations most commonly associated with such errors.

Content

The study found that in total, 28,217 reports were identified, with 608 relating to moderate-severe harm or death. Of the 5708 reports coded, 642 described an HTA step discrepancy (including four linked to a death), suggesting over 3200 discrepancies in the entire dataset of 28,217 reports. Discrepancies related to finding guidelines, finding information within guidelines and using information. Discrepancies were most frequently identified for guidelines produced by a local organisation, and most occurred during prescribing or medication administration.

The authors concluded that difficulties finding and using information from clinical guidelines contribute to thousands of prescribing and medication administration incidents, some of which are associated with substantial patient harm.