Evaluation of the Medication Never Events and Related Factors: A Nationwide Database Study

Abstract

Background: The present study was conducted to evaluate the prevalence of medication errors regarded as never events in Iran and the related factors and develop a strategic operation plan (SOP) for its prevention. Materials and Methods: A nationwide cross-sectional study with a documentary approach was conducted. For this purpose, all documented reports of medication-never events (over 515 cases) were extracted from the hospital Information system (HIS) of Iran between 2018 and 2020. After reporting each error, using root cause analysis (RCA), factors related to each medication never event were identified. Results: According to the evaluations, the errors caused by the name/type of medication and medication administration errors had the highest percentages, 38.4% and 25%, respectively. 14.8% of patients were infants, 13.4% children, 4.3% youth, 43.7% adults, and 23.9% were elderly. Among healthcare providers (HCP), nurses were individuals who committed these errors the most (72.2%). Analyzing the causes and factors related to error incidence, the negligence of health-care personnel, the negligence of the patient or his companion, work environment problems, name problems, packaging and drug labels, negligence in responsibilities, problems of computer information systems, and handwritten prescriptions were found to be the most common factors related to the occurrence of medication never events. Conclusion: The results revealed that strategies contributing to the minimization of each type of error may include education of the patient or healthcare provider. By implementing a computer-based system for medication review and reconciliation process, prioritizing areas that can be quickly modified, might be more feasible.