Analysis of patient safety incidents reported by community pharmacists from 2019 to 2021 in South Korea

Sukyeong Kim, Su-Jin Kim,Jiyun Yang, Eun Hye Lee, Na-Young Kim, Kihyun Sung, Mo-Se Lee

Regional Patient Safety Center, Korean Pharmaceutical Association, Seoul, Republic of Korea

 

INTRODUCTION

Medication errors (MEs) are the most frequently reported patient safety incident and a major problem in patient safety.¹⁾ In South Korea, 500 million outpatient prescriptions were issued as of 2019,²⁾ and most of them were dispensed at community pharmacies and delivered to patients. Therefore, community pharmacies can play an important role in improving medication safety. The Korean Pharmaceutical Association (KPA) has received patient safety incident reports from community pharmacies nationwide through the online application system (KPA Adverse Event and Patient Safety Incident Reporting System: KPA SafePharm System) since 2019.KPA reviews these reports and reports to the Korea Patient Safety Reporting & Learning System (KOPS) ³⁾ of the Korea Institute for Healthcare Accreditation under the Ministry of Health and Welfare. KPA analyzes the received reports as well and shares the results with community pharmacists for supporting MEs prevention activities. This study analyzed the details of MEs, and related actions reported by community pharmacists.

AIM

We analyzed the reports from community pharmacies to figure out the types of errors, frequency, degree of harm, related medicines, and pharmacists' actions. We could have useful information on the patient safety activities in community pharmacies and set the targets that should be approached with priority to prevent similar incidents recurring from the results.

METHODS

 Patient safety incident reports received from community pharmacies through the ‘KPA SafePharm System’ from January 2019 to December 2021 were analyzed. WHO and IOM's incident stage and type classification standardswere modified and applied. Incidents related pharmaceuticals were analyzed based on Anatomical Therapy Chemical (ATC) Classification system level 2. Three pharmacists had participated in coding and cross-checking the data. The cases which could not be identified in the reports were classified as “missing”.

RESULTS

[Analysis of all errors]

[Analysis of Prescribing and Dispensing errors]

[Analysis of Administering errors]

CONCLUSION

The prescribing errors were the highest proportion of the MEs reported. In MEs of the prescribing phase, ‘wrong drug’ was the most frequently reported. And therapeutic duplication in ‘wrong drugs’ cases of the prescribing phase was the most reported. Community pharmacists’ actions to the prescribing errors were consult prescriber to change the prescription and patient education. There were few severe harms reported. In MEs of the dispensing phase, ‘wrong count’, ‘wrong dose’ and ‘wrong drug’ were frequently reported. To improve medication safety of prescribing process, the pharmacist consultation to prescribers needs to be strengthened. For dispensing errors prevention, community pharmacy needs to have intra-double-checking system. However, there were few reports of dispensing errors compared to the prescribing errors, so there was a limit to obtaining accurate results. It is our future task to activate dispensing error reporting of community pharmacists.

REFERENCE

1)      Kohn, L.T.; Corrigan, J.M.; Donaldson, M.S. (Eds.) To Err is Human: Building a Safer Health System; National Academies Press: Washington, DC, USA, 2000.

2)     ‘처방일수별 요양기관종별 원외처방횟수’ 「2019년 건강보험통계」 Korean Statistical Information Service. Available online: http://m.site.naver.com/1bJQ1 (accessed on 24 July 2023)

3)     The Bulletin board of Korea Patient Safety Reporting & Learning System. Available online:   https://www.koiha-kops.org/main.do(accessed on 28 July 2023).