Table 29 'Medication Error'

PSI 28: Medication Error
Origin: Review of an OECD PSI (33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Medication errors are known to be fairly common but preventable
events. Medication errors refer to errors in processes of ordering,
transcribing, dispensing, administering, or monitoring medications.
Many medication errors are thought to have no or few consequences
for the patient’s health by health care workers also many medication
errors are thought undetected. Though medication errors may result in
serious patient morbidity or mortality. Patient compliance has an
impact on preventing medication errors. Medication errors are a
suitable theme for measuring patient safety.
Aim of the PSI This PSI is intended to flag cases of in-hospital medication errors.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) Originally a JCAHO sentinel event indicator
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21 cover
patient safety (33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Medication Errors”.
Data definitions Not specified by OECD.
Numerator Description Number of patient deaths, paralysis, coma, or other major permanent
loss of function associated with a medical error.
Denominator Description According to the SimPatIE Stepwise Assessment Indicator Framework
Approach, this PSI is not described further as the denominator is not
defined by OECD or by JACHO.