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13 Thematic review of medication-related incidents at a major teaching hospital and the potential mitigation of these incidents with electronic prescribing and medicines administration
  1. Adam Khimji
  1. University of Nottingham/Birmingham Community Healthcare NHS Foundation Trust


Objective To describe the frequency of the different types of harmful medication related incidents reported from one NHS Trust. To then assess whether the likelihood of these incidents occurring would have been reduced by a specific ePMA system, Nervecentre.

Methods Two researchers retrospectively reviewed 387 medication related incidents reported to DATIX, a national reporting system, between September 2020 and August 2021 at Nottingham University Hospitals NHS Trust.

The incidents only involved hospital inpatients and had to be associated with patient harm. Descriptive statistics were used to describe the frequencies and percentages of incidents per type of medication-related error, degree of harm, hospital division and specialty. Incidents were classified based on the extent to which Nervecentre could have reduced the likelihood of the incident occurring.

The actions from this review were adopted into project planning, risk management and deployment planning with a view to repeating the review pre-deployment.

Results Administration incidents were commonly reported (179 incidents, 46.3%), with the Prescribing, Pharmacy and Discharge categories containing fewer incidents. Hospital divisions reported similar frequencies of incidents, with more variation observed between specialties. While most incidents were not likely to be impacted by ePMA (243 incidents, 63.1%), Nervecentre could have reduced the likelihood of 72 incidents (18.6%).

Configuration and development to the system had the potential to reduce the likelihood of a further 29 (7.2%) and 43 (11.1%) incidents, respectively. Analysis of harm suggested that the likelihood of approximately 1 in 5 moderate harm incidents could have been reduced by Nervecentre (without configuration).

Conclusion Implementation of Nervecentre would likely be an effective intervention to reduce many types of harmful medication-related incidents at this Trust. Alternative interventions are required to mitigate errors that would not be impacted by ePMA systems.

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