[Impact of the COVID-19 pandemic on patient safety incident and medication error reporting systems]

A retrospective analysis of adverse events reported by Tunisian intensive care units' professionals

INTRODUCTION

Adverse events (AEs) that occur in hospitals remain a challenge worldwide, and especially in intensive care units (ICUs) where they are more likely to occur. Monitoring of AEs can provide insight into the status and advances of patient safety. This study aimed to examine the AEs reported during the 20 months after the implementation of the AE reporting system.

METHODS

We conducted a retrospective analysis of a voluntary ICU AE reporting system. Incidents were reported by the staff from ten ICUs in the Sahloul University Hospital (Tunisia) between February 2020 and September 2021.

RESULTS

A total of 265 reports were received, of which 61.9% were deemed preventable. The most frequently reported event was healthcare-associated infection (30.2%, n = 80), followed by pressure ulcers (18.5%, n = 49). At the time of reporting, 25 patients (9.4%) had died as a result of an AE and in 51.3% of cases, the event had resulted in an increased length of stay. Provider-related factors contributed to 64.2% of the events, whilst patient-related factors contributed to 53.6% of the events. As for criticality, 34.3% of the events (n = 91) were unacceptable (c3) and 36.3% of the events (n = 96) were 'acceptable under control' (c2).

CONCLUSIONS

The reporting system provided rich information on the characteristics of reported AEs that occur in ICUs and their consequences and may be therefore useful for designing effective and evidence-based interventions to reduce the occurrence of AEs.

Detection and Prevention of Medication Errors by the Network of Sentinel Pharmacies in a Southern European Region

A medication error (ME) is a drug-related problem that has been recognized as a common and serious threat to patient safety. The aim of this study was to detect and analyze ME reports occurring throughout the therapeutic process through the community's pharmacies in order to improve the efficacy and safety of medications and contribute to the prevention of future MEs. This was a three-year descriptive, observational, and prospective study to detect and analyze the different MEs reported by the Catalan sentinel pharmacies network (Catalan SePhaNet). In total, 1394 notifications of MEs were reported (an incidence rate of 737.34 cases/100,000 inhabitants). MEs were detected more frequently in primary care centers. Most of the MEs reported were caused by an incorrect, incomplete, illegible, or verbal medical prescription (41.3%). Of the global notifications detected, 71.9% did not reach the patient (categories A and B). The drugs most frequently implicated in the reported ME cases were beta-lactam antibiotics. In 6.0% of the cases, the ME caused injury to the patient (categories E and F). In 72.0% of the global notifications, a pharmacist's intervention avoided the ME. The importance of a community pharmacy and the role of a pharmacist were demonstrated in aspects related to patient and drug safety.