Medication Error Management Using Risk Register in a Sub-District Health Promotion Hospital, Nakhonratchasima Province

Abstract

Objectives: To develop a system to reduce medication errors (MEs) in sub-district health promoting hospitals (SDHPH) by using the risk register. Methods: This study was an action research divided into 4 phases: 1) risk identification based on the incidence of MEs, 2) risk analysis based on the size and severity of the problem, 3) risk management by brainstorming to design risk reduction measures, and 4) monitoring and review of risks from MEs incidence data. After the implementation of risk register, the researcher collected data by a mixed method. Qualitative methods included observations, interviews and meeting arrangements, while quantitative methods included prescription reviews to analyze the incidence of MEs. Results: Problems that were selected for risk registration and root cause analysis were dispensing expired drug with grade D severity, dispensing the wrong strength and dispensing the wrong quantity of drugs, which were common incidences. Measure to prevent drug expiration included the creation of an expired drug monitoring system. Measures to prevent the wrong amount of drugs included changing dispensing to make it easier to check the amount, and revising the checking system. Measures to prevent errors on wrong strength were using stickers with different colors for drug with different strengths and changing the rechecking system.  After the introduction of the risk register, it was found that the incidence of dispensing the wrong potency decreased from 0.12% to 0.07%. The incidence of dispensing the wrong amount decreased from 0.24% to 0.21%, while the incidence of dispensing expired drugs decreased from 0.06% to 0. The staff at the SDHPH viewed risk register as a tool that provided an overview of the problem. However, the form should be revised to be concise and easy to record data. Conclusion: The development of a system to prevent MEs using a risk register is likely to help prevent MEs, but the form should be revised to make it more convenient to use.