[O4] TO ERR IS HUMAN: LEARNING FROM MEDICATION ERRORS IN HIV

10th Anniversary Conference Of The British HIV Association [BHIVA]

15 – 17 April 2004, City Hall, Cardiff, UK

[TITLE:] TO ERR IS HUMAN: LEARNING FROM MEDICATION ERRORS IN HIV

[AUTHOR(S):] H Leake Date¹, D Godfrey², Jane Nicholls³, on behalf of HIVPA⁴
¹ Brighton and Sussex University Hospitals NHS Trust, ² Mayday University Hospital, ³ London, Eastern and South East Specialist Pharmacy Services, ⁴ The HIV Pharmacy Association (HIVPA), UK

BHIVA Conf 2004 Apr 15-17;10:O4

INTRODUCTION: A Department of Health (DH) report on improving medication safety (Building a Safer NHS for Patients) highlighted the causes and frequency of medication errors and identified strategies for preventing them. Previous HIVPA research showed that 2.8% HIV outpatient prescriptions contained serious errors.

METHODS: HIVPA members recorded all serious (moderate, major or catastrophic) medication errors relating to people with HIV for one week [using National Patient Safety Agency (NPSA) criteria] and the results were analysed using Microsoft Excel. All errors were peerreviewed and 'most likely consequences if not detected' were classified as 'catastrophic' (e.g. could be fatal), 'major' (e.g. could cause virological failure) or 'moderate' (e.g. could cause renal failure).

RESULTS: 76 serious errors were detected by 10 centres. 11 (14%) resulted in actual harm, two (3%) caused no harm and 63 (83%) were 'near misses' (detected before the patient received medication). Probable outcomes of all errors if undetected were peer-reviewed as: catastrophic (1.3%), major (54%) and moderate (44.7%).

DISCUSSION: The human and financial ramifications of medication errors are enormous. This survey highlights significant clinical risks and training needs for HIV multidisciplinary teams. Strategies are needed to improve patient safety and meet the DH target of a 40% reduction in serious medication errors.

PRESENTING AUTHOR: H Leake Date

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Copyright © 2004 - British HIV Association (BHIVA) Reproduction of this abstract (other than one copy for personal reference) must be cleared through the BHIVA Organising Secretariat 1 Mountview Court, 310 Friern Barnet Lane, London N20 0LD