Medication Errors in a Specialist Palliative Care Unit

Dear Editor:

Discussing errors in clinical practice is difficult ¹ but is an essential part of any quality improvement program. Information about medication errors in palliative care units is sparse but there have been attempts to benchmark inpatient medication errors in one area of the United Kingdom. ² In that review almost all medication errors were classified as either insignificant or minor and compare well with the reported error rate in hospital patients in the United States of between 2% and 14%. ³

As part of the quality program at our inpatient facility, reporting all medication incidents, however apparently insignificant, is encouraged as a means of identifying system and process failures to facilitate quality improvement.

Medication errors or adverse events are reported in a number of areas as varying from 1.19 to 7.26 incidents per resident ⁴ up to a possible upper rate of 19% of errors identified by observational methods. ⁵

Voluntarily reported medication errors are collected using an exception/audit form completed by any staff member in the inpatient unit who observes a medication error or perceived medication error.

Results of the 2008/2009 and 2009/2010 audits are compared (Table 1).

Many commentators highlight the role of poor systems in contributing to the occurrence of medication incidents.^6–8 This ongoing review emphasizes the inevitability of human error and the necessity for us to ensure that systems supporting human functioning, especially in the area of medication management are as simple as possible. Managers have a role to play in determining culture and designing and implementing systems; educators have a role in informing and training; clinicians, who understand the practical issues regarding medication management and can identify processes that are likely to either succeed or fail should all be involved. There have been no adverse clinical outcomes resulting from medication errors throughout this reporting period. We would value the experience of others in this aspect of practice.