Relationship between incident types and impact on patients in drug name errors: a correlational study

Abstract

Background: There are many reports regarding various medical institutions' attempts at incident prevention, but the relationship between incident types and impact on patients in drug name errors has not been studied. Therefore, we analyzed the relationship between them, while also assessing the relationship between preparation and inspection errors. Furthermore, the present study aimed to clarify the incident types that lead to severe patient damage.

Methods: The investigation object in this study was restricted to "drug name errors", preparation and inspection errors in them were classified into three categories (similarity of drug efficacy, similarity of drug name, similarity of drug appearance) or two groups (drug efficacy similarity (+) group, drug efficacy similarity (-) group). Then, the relationship between preparation and inspection errors was investigated in three categories, the relationship between incident types and impact on patients was examined in two groups.

Results: The frequency of preparation errors was liable to be caused by the following order: similarity of drug efficacy > similarity of drug name > similarity of drug appearance. In contrast, the rate of inspection errors was liable to be caused by the following order: similarity of drug efficacy < similarity of drug name < similarity of drug appearance. In addition, the number of preparation errors in the drug efficacy similarity (-) group was fewer than that in the drug efficacy similarity (+) group. However, the rate of inspection errors in the drug efficacy similarity (-) group was significantly higher than that in the drug efficacy similarity (+) group. Furthermore, the occupancy rate of preparation errors, incidents more than Level 0, 1, and 2 in the drug efficacy similarity (-) group increased gradually according to the rise of patient damage.

Conclusions: Our results suggest that preparation errors caused by the similarity of drug appearance and/or drug name are likely to lead to the incidents (inspection errors), and these incidents are likely to cause severe damage to patients subsequently.

Keywords: Drug name errors; Impact on patients; Incidents; Inspection errors; Preparation errors.

Figure 1

Number of preparation and inspection errors in three categories (A) and two groups (B). The total numbers of preparation and inspection errors involved in drug name errors were 704 and 73, respectively. Also, the numbers of preparation and inspection errors in three categories (similarity of drug efficacy, similarity of drug name, similarity of drug appearance) or two groups (drug efficacy similarity (+) group, drug efficacy similarity (−) group) were 600 and 66, respectively. The preparation and inspection errors were classified into seven error types (A) and two error groups (B). Numerical values in the circle represent the number of preparation errors (inspection errors).

Figure 2

Relationship between number of preparation errors and rate of inspection errors in four classes. The numbers of preparation errors in three classes (single similarity class, double similarity class, triple similarity class) were 338, 228, and 34, the rates of inspection errors in the same classes were 12.7% (43/338), 9.6% (22/228), and 2.9% (1/34), respectively. The bar and symbol represent the number of preparation errors and the rate of inspection errors, respectively. The differences in the rates of inspection errors were analyzed among four error classes (single, double, triple and no similarity class). There were no significant differences in the rates of inspection errors among four classes (P = 0.1305). The data were analyzed with a Chi-squared test. P values of <0.05 were considered to be statistically significant.

Figure 3

Relationship between number of preparation errors and rate of inspection errors in the single and double similarity class. In the single similarity class, the numbers of preparation errors in the error type (a), (b), (c) were 242, 74, 22, and the rates of inspection errors in the same error type were 10.7% (26/242), 14.9% (11/74), 27.3% (6/22), respectively. In the double similarity class, the numbers of preparation errors in error types (d), (e), (f) were 163, 49, 16, and the rates of inspection errors were 6.7% (11/163), 14.3% (7/49), 25.0% (4/16), respectively. The bar and symbol represent the number of preparation errors and the rate of inspection errors, respectively. The differences in the rates of inspection errors were analyzed among three error types (a) - (c) in the single similarity class and another three error types (d) - (f) in the double similarity class. There were significant differences in the rates of inspection errors between error type (a) and (c) in the single similarity class, between error type (d) and (f) in the double similarity class (P < 0.05). The data were analyzed with a Ryan test. P values of <0.05 were considered to be statistically significant.

Figure 4

Relationship between number of preparation errors and rate of inspection errors in two groups. The number of preparation errors was 488, and the rate of inspection errors was 9.2% (45/488) in the drug efficacy similarity (+) group. The number of preparation errors was 112, and the rate of inspection errors was 18.8% (21/112) in the drug efficacy similarity (−) group. The bar and symbol represent the number of preparation errors and the rate of inspection errors, respectively. The differences in the rates of inspection errors were analyzed between two groups (drug efficacy similarity (+) group, drug efficacy similarity (−) group). There was a significant difference in the rates of inspection errors between two groups (P < 0.05). The data were analyzed with a Chi-squared test. P values of <0.05 were considered to be statistically significant.

Figure 5

Relationship between incident types and impact on patients. The occupancy rates of preparation errors, incidents more than Level 0, 1, and 2 in the drug efficacy similarity (+) group were 81.3% (488/600), 68.2% (45/66), 57.1% (4/7), and 25.0% (1/4), respectively. On the other hand, the same rates in the drug efficacy similarity (−) group were 18.7% (112/600), 31.8% (21/66), 42.9% (3/7), and 75.0% (3/4), respectively. Consequently, the occupancy rate of preparation errors, incidents more than Level 0, 1, and 2 in the drug efficacy similarity (−) group increased gradually according to the rise of patient damage.