Given the broad range
of potential causes of medication incidents, clinical and system reviews should
be conducted to identify potential causes and determine appropriate
Occurrences of harm
are often complex with many contributing factors. Organizations need to:
- Measure and monitor the types
and frequency of these occurrences.
- Use appropriate analytical
methods to understand the contributing factors.
- Identify and implement
solutions or interventions that are designed to prevent recurrence and reduce
risk of harm.
- Have mechanisms in place to
mitigate consequences of harm when it occurs.
To develop a more
in-depth understanding of the care delivered to patients, chart audits, incident analyses and
prospective analyses can be helpful in identifying quality improvement
opportunities. Links to key resources for conducting
chart audits and analysis
methods are included in the Hospital
Harm Improvement Resources Introduction.
If your review
reveals that your medication incidents are linked to specific processes, you
may find these resources helpful:
- Institute for Healthcare Improvement (IHI). www.ihi.org
- Canadian Patient Safety Institute. https://www.patientsafetyinstitute.ca
- Medicines and Prescribing Centre. NICE
guidelines: Medicines optimisation: the safe and effective use of medicines to
enable the best possible outcomes. http://www.nice.org.uk/guidance/NG5/