Browsing by Subject "lääkityspoikkeama"
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(2021)Medication errors due to infusion pump programming errors are common in neonatal intensive care units and often lead to overdoses of medicines. Medication errors can be prevented with dosing limits set into the smart infusion pump drug library. However, alert fatigue caused by unnecessary alarms has been identified to hinder their use. To ensure the benefit of dosing limits as a defence of intravenous medication process, the aim of this study was to define the dosing limits to the drug library for certain high alert medications, and to pilot them in the neonatal intensive care unit. The study was based on the theoretical framework of preventive medication risk management. Based on the results, the suitability of the dosing limits for the use of the unit and the patient group was assessed. This mixed method study employed register-based research methods. The research data consisted of the infusion rate related medication errors (n=21) reported to the HUS HaiPro-system between January 2018 and December 2019 in the HUS Neonatal Intensive Care Unit. The data was analysed qualitatively and quantitatively to describe the infusion rate related errors, and to identify their mechanisms and contributing factors. Based on the identified mechanisms of the errors, simulated test patient cases were developed. Dosing limits were defined by a multidisciplinary expert group for certain high alert medications, and their suitability for preventing medication errors was investigated by programming infusion pumps according to the test patient cases and analysing the pump alerts. Based on the identified mechanisms of infusion rate-related medication errors (n=21) in the HaiPro-reports, 2-, 5-, and 10-fold infusion rates as well as mixing of infusion rates between medicines were established as test patient cases. As a result of the tests (n=226), the infusion pumps did not alert when programming normal infusion rates (n=32) and 73% (n = 70/96) of the erroneous 2-, 5-, and 10-fold infusion rates were prevented. 10-fold infusion rates were inhibited in all cases (n=32). Interference of infusion rates between medicines was prevented in 24% (n=24/98) of the cases. According to this study, significant infusion rate related medication errors can be prevented in the neonatal intensive care unit with the multidisciplinarily defined dosing limits set in the infusion pump drug library. However, they do not prevent all the infusion rate related medication errors alone, and therefore additional defences are needed. In addition to the neonatal intensive care unit, the method used in this study to define and test the dosing limits may be applied in other pediatric units in the future. By using this method, the suitability of the dosing limits for the use of the unit and the patient group can be ensured before integration of the barrier and thereby promote the benefits of its use. The suitability of the dosing limits set into the infusion pump drug library should be assessed again after implementing the defence into the neonatal intensive care unit.
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(2023)Medication safety is an important target of development in health and social services systems internationally. Medication errors are one of the biggest risk factors in medication safety. Majority of the medication incidents could be avoided by improving the medication treatment process. Patient safety incident reporting systems enable health and social services to collect systematic data from risk factors within the medication treatment process. This study was conducted as a retrospective registry-based study where medication incidents that occurred in health and social care units reported by community pharmacies to the incident reporting system HaiPro from 21st of September 2021 to 31st of October 2022 were analysed. Cases that did not meet the criteria for this study (n=55) were removed from the original data (n=3841). If needed, the nature and type of the reported error were corrected. A descriptive quantitative analysis was conducted for the final data (n=3786) using Microsoft Excel. The number, natures, types, observers, and prescription types of medication errors were investigated from the data. In addition, the most common groups of medicinal substance and high risk medicines were identified. A qualitive content analysis was performed to near miss cases involving high-risk medications (n=446) using the Atlas.ti program. Interventions, measures following the interventions and risks prevented by the measures were identified from the open description in the incident reports. The qualitative analysis was performed as an abductive content analysis. Of the medication errors included in the study (n=3786) 91% were detected by community pharmacies and the majority (68%) of the reported incidents were near misses. Most (96%) of the safety incidents (n=3786) were associated with the patient’s medication treatment and had occurred mostly during the prescribing process (92%). As a result from the prescribing errors, patients were most commonly prescribed wrong dose or strength of the medicine (26%) or the prescription lacked SIC marking (26%). High-risk medications occurred in 16% (n=591) of the incidents (n=3786). Most frequently detected high-risk medications were opioids (35 %). Three quarters (76 %) of safety incidents associated with high-risk medications were near misses (n=446). The majority (92 %) of interventions (n=471) made to prevent safety incidents associated with high-risk medications were made by community pharmacies. The most frequent intervention was community pharmacies contacting the doctor. Based on the HaiPro incident reports made about medication errors in health and social care units reported by community pharmacies, it can be concluded that community pharmacies are a central barrier in primary care medication treatment process. Community pharmacies detect and report medication errors that have occurred in other health and social care units. Safety incidents reported by pharmacies systematically accumulate important information that can be used in the development of medication safety in primary care at a unit, wellbeing services county and national levels.
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(2021)Background and objectives: Documenting and processing of dispensing errors at both organizational and national levels is one of the basic preconditions for effective medication risk management. Since the most recently accomplished national register research of dispensing errors in Finland, there have been several changes in the medication dispensing process that advance medication safety. Thus, the previous study does not provide an up-to-date picture of the current situation. The primary objective of this study was to find out the trends in dispensing errors that were reported to the Finnish Pharmacy Association's registry of dispensing errors in 2015–2019. The secondary objective was to identify risk factors expository to dispensing errors in the dispensing process and to review the measures utilized by community pharmacies to prevent dispensing errors. Materials and methods: The retrospective registry study, in which the register of dispensing errors maintained by the Finnish Association of Pharmacists for the period from 1 January 2015 to 31 December 2019, was analyzed. Cases that did not fulfil the definition of a dispensing error (n=829) were removed from the original data (n=17763). In addition, clear errors (n=2130) were corrected in the data and cases (n=499) that were initially insufficiently entered in the register were added. 17433 dispensing errors were included in the study. The data was analyzed using Microsoft Excel. The number, qualities, prescription types, observers, therapeutic harms and contributory factors of the dispensing errors were investigated in the data. The most common groups of medicinal substance, high-alert medications and risk factors in the medication dispensing process were identified in the data. In addition, interventions reported by community pharmacies to prevent dispensing errors were collected from the data. Results: The number of cases reported to the dispensing error register has decreased annually (2015 n=3913, 2016 n=3795, 2017 n=3708, 2018 n=3578, 2019 n=2439). The most common types of dispensing errors are incorrect strength (51 % of all the reported dispensing errors) and incorrect quantity or package size (14 %). Slightly more than a half (51 %) of the reported dispensing errors were noticed by medicine users. The percentage of electronic prescriptions in dispensing errors has increased and is clearly the most common prescription type in dispensing errors (2015: 79 %, 2016: 84 %, 2017: 93 %, 2018: 96 %, 2019: 95 %). The majority of dispensing errors occurred with cardiovascular medicines (29 %) and medicines affecting the nervous system (26 %). 7 % of dispensing errors caused therapeutic harm to the medicine user. As a result of dispensing errors, 21 medicine users were hospitalized. 13 % of dispensing errors occurred with high-alert medications (n=2244). The high-alert medications were involved in one-third (n=7) of dispensing errors that led to hospitalization. Factors related to the employee (25 %), similar packaging (19 %), and similar medicine name (15%) were most commonly considered to be the main contributory factors for the occurrence of the dispensing errors. The risk factors identified in the medicine dispensing process were related to the pharmacy system, the characteristics of the prescription, the storage method of the medicine and the characteristics of the medicine packaging. In the automated dose dispensing process, the risk of dispensing error increased if changes had to be made to the dose dispensing order. The risk factors for automated dose dispensing were related to the pharmacy system and the characteristics of the prescription. The community pharmacies had mentioned taking measures to prevent dispensing errors in one-fifth (21 %) of the reported cases. In addition to developing their own operations, community pharmacies saw cooperation with other healthcare professionals as an important factor in preventing medication errors. In addition, community pharmacies reported exposing properties for dispensing errors of pharmaceutical products and systems to pharmaceutical companies and providers of pharmacy systems and automated dose dispensing. Conclusions: Trends, risk factors of the dispensing process and interventions to prevent dispensing errors can be identified in the dispensing errors reported to the Finnish Association of Pharmacists’ dispensing error registry. The dispensing error register provides valuable information on dispensing errors at the national level, but it is no longer able to fulfil completely the current medication safety needs. In the future, the role of the pharmacy as a promoter of medication safety should be perceived as more comprehensive. In the development of medication safety, special attention should be paid to the risk factors of the dispensing process, the high-alert medications and to new risks arising from the increase of electronic prescriptions and automated dose dispensing. In addition, cooperation between pharmacies and other healthcare professionals and the medication safety culture of pharmacies should be further strengthened.
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(2020)Medication-related errors have been identified as the single most important risk factor for patient safety across the world. According to previous research, medication errors are common in nursing homes. However, the existing data on medication errors in Finnish nursing homes is scarce, although the challenges and defects in nursing home care services, including drug treatments, are well known. Furthermore, nursing home residents are typically characterized by old age, multimorbidity and polypharmacy. Therefore, they are particularly vulnerable to potential adverse events caused by medication errors. The aim of this study was to investigate the rates and causes of medication errors reported in nursing homes and evaluate their impact on medication safety. Additionally, the proportions of potentially inappropriate medication (PIMs) and high-risk medication involved in the medication errors were determined. The data of the study consisted of 251 medication errors reports that were submitted to the safety incident report system (HaiPro) in nursing homes located in Central Uusimaa healthcare and social welfare joint municipal authority (Keusote) in 2019. Quantitative analysis of the data provided an overview of the medication errors that had occurred in nursing homes and the medicines most commonly involved in them. Content analysis and simplified root cause analysis enabled to study more in-depth the contributing factors of medication errors and potential risks associated with the medication process in nursing homes, as well as the possibilities of preventing similar errors in the future. James Reason's human error theory and in particular its system perspective was applied as a theoretical framework in this study. Medication errors were reported regularly in nursing homes during the follow-up period of the study. The most frequent medication error type was administration error. The majority of these errors were medication omissions, followed by the wrong time of administration and administration to the wrong patient. The most common drug classes causing medication errors were antithrombotics, opioids, antidementia drugs, diuretics, antipsychotics, antidiabetics, and antidepressants. Nearly a quarter of the reported medicines were high-risk medications, most commonly opioids, antithrombotics, or antidiabetic drugs. PIMs accounted for approximately 13% of all medications in the data. Errors were most often caused by unsafe medication practices, communication problems, and deficiencies in the work environment such as excessive workload or time pressure. A significant part of the medication errors were related to transdermal medication patches. The study also showed that the quality of medication error reporting in nursing homes is in part insufficient and should be improved so that the reports can be better used for learning purposes. The results of the study provide valuable additional information on medication errors in Finnish nursing homes and their contributing factors. The information can be used to improve medication safety practices in nursing homes. Safe and uninterrupted medication use process is a goal that should be pursued not only in health care but also in social welfare services such as nursing homes.
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(2013)About 10 % of the patients experience an adverse event during their treatment. About 1 % of the adverse events are serious. Extrapolated from international evidence adverse events cause death of 700 - 1700 patients annually in Finland. Medication errors are the most common single preventable cause of adverse events. According to several studies about half of the adverse events and medication errors are preventable. Therefore medication safety is a central part of the Finnish Patient Safety Strategy. One of the medication safety tools in Finland is unit-based pharmacotherapy plan for which the Ministry of Social Affairs and Health gives instructions in the Safe Pharmacotherapy guide. All social and healthcare units should develop a pharmacotherapy plan which describes the medication processes in the unit. The purpose is to harmonise the principles for the provision of pharmacotherapy, to clarify the division of responsibilities related to its provision, and to define the minimum requirements that must be complied. The aim of the study was to explore how the pharmacotherapy plans were made and to evaluate their implementation and benefits in hospitals, health centres and social care units for the elderly. Pharmacotherapy plans are studied as part of the Finnish Patient Safety Strategy, focusing on medication safety. Head nurses were chosen as target group. The data was collected by phone interviews. Forty (8 %) interviews were received from a random sample that was taken from a register of head nurses held by Tehy ry. The interview was semi-structured theme interview and the data was analysed using content analysis. Most of the studied units (n= 24, 60 %) had started to formulate the pharmacotherapy plan in 2007, soon after the Safe Pharmacotherapy guide was published. Pharmacotherapy plans were drawn up on organisation and/or unit level. There was a lot of variety in the working groups' sizes and professionals taking part in them. More instructions would have been needed. The most common way (n=20, 50 %) to induct the pharmacotherapy plan to the staff was to introduce it at the unit meeting. Most commonly mentioned changes to the operations in the units were related to error reporting (n=15, 38 %), certification procedures for distribution and administration of medicines (n=9, 23 %) and task allocation (n=8, 20 %). There were several benefits of the pharmacotherapy plan of which most common were starting or developing error reporting (n=19, 48 %), clarification and better availability of instructions (n=18, 45 %), better induction of new staff members and substitutes (n=16, 40 %) and standardization of procedures (n=10, 25 %). Allocation of tasks and responsibilities was considered a challenge in developing and using the pharmacotherapy plan. Limited resources caused difficulties in implementing and using the pharmacotherapy plan. The staffs' medication education was kept more up-to date after introduction of the pharmacotherapy plan but the education was also challenging for the units. Pharmacotherapy plans made the units develop their procedures and increased understanding of medication safety. All in all the plans have worked well as part of the Patient Safety Strategy. However the systematic development of the pharmacotherapy and the use of pharmacotherapy plans in social and healthcare units requires more effort.
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(2020)Between 5% and 57% of patients experience an adverse drug event during their hospitalization. Reducing medication errors can help prevent adverse drug events. A particular risk for medication errors arises when a patient moves between home and care centers if accurate medication information is not transferred with the patient. Medication reconciliation is a process to ensure accurate and comprehensive medication information across transitions of care. The aim of the study was to find out how many and what kind of discrepancies can be detected by performing medication reconciliation in a primary care unit. In addition, pharmacists and nurses experiences of the medication reconciliation process and the medication reconciliation form were examined. Both quantitative and qualitative data were used in the study. Quantitative study data consisted of all Medication reconciliation forms (PASQ) completed in January-June 2014. Data were analyzed using quantitative descriptive methods. The qualitative research material consisted of six individual interviews conducted in June 2014. The material was subjected to inductive thematic content analysis. Patients (n = 117) had a mean age of 81 years and almost all (n = 105) had at least six regularly used medications after medications were reconciled. Almost every patient (n = 115, 98.3%) had at least one discrepancy in their medication compared to the patient information system. On average, patients had seven discrepancies in their medication lists. The most discrepancies were associated with psycholeptics (9.5% of all discrepncies). The most common types of discrepancies were new drug (45.4% of all discrepancies) and discontinued drug (19.6%). Nurses and pharmacists saw the medication reconciliation process as an important part of successful patient care. Challenges associated with reconciling medications were caused by lack of time, the fragmentation of information systems and the health status of patients (information given by patients could not be trusted). Only one-third of the patients were interviewed, although international publications on medication reconciliation strongly emphasize patient involvement. The results of this study are in line with previous research and confirm the view that medication reconciliation should always be done across all transitions in care. The role of the patient as part of the medication reconciliation process should be further emphasized in the future, as only interviewing the patient can provide a true picture of the patient's medication.
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(2015)Background: Medication errors are the most important individual factor that jeopardizes patient safety in human care. The patient's medication process is a chain of successive operations which involves different health care providers and the medicine user. All the stages of the medication process are susceptible to the medication errors. Medication errors are approached from the system's point of view by James Reason`s (1990) theory of Human Error. Instead of blaming individuals the theory concentrates on developing operations models which enable identification of medication errors in the organizations. The development of medication safety culture in the human medication has led to systems which tolerate human mistakes and prevent errors. The increasing number of animals and pets and their changing status in the society have raised discussion about the medication safety in veterinary care. Little research has been conducted in this field. Objective: The objective of the study was to identify the most typical veterinary medication errors and their root causes. The medication management processes of veterinary care can be developed safer by becoming aware of the root causes of medication errors. Study design and data: All the cases investigated by the Assessment Board for Damages in Veterinary Practice in 2002-2013 considering medication errors (n=79) were analysed with the help of the structured data collection sheet by using descriptive statistics. The most typical cases were studied more in detail by using simplified Root Cause Analysis (RCA). Results: The medication errors found were related to the care of dogs (n=34), horses (n=26), bovines (n=10), cats (n=7) and pigs (n=2). The most general therapeutic groups that had caused medication errors were antibacterials for systemic use (17% of all the medicines related to the medication errors), NSAIDs and antirheumatic drugs (12%), neuroleptics and tranquillizers (12%), and analgesics (12%). Of the drugs, 39% were high alert medicines. Of the errors, 36% were related to the off label use (usage deviating from the summary of product characteristics, SPC). The error types which appeared most commonly in the cases were wrong route of administration (18% of all the medication errors), wrong dose (16%) and untreated diagnosed conditions left without the medicine by the veterinarian (15%). Because of the character of the data the majority of the medication errors occurred in the beginning of the medication process. It was estimated that 81% of the medication errors would have been preventable. Some of the root causes found were the lack of the commitment to the established care practice, environmental factors, communication problems, availability of tools, hurry and factors related to management, information and staff. Conclusion: The material of Assessment Board for Damages in Veterinary Practice gives valuable information about the veterinary medication errors. It is possible to influence the root causes of veterinary medication errors by paying attention to the management related factors and communication in veterinary care and improving access to therapeutic guidelines and electronic databases, and by expanding the electronic prescribing to veterinary care. The highest priority is to get Pharmaca Fennica Veterinaria to an electronic form.
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(2013)Ensuring patient and medication safety is a widely acknowledged challenge in health care. Key concepts in medication safety are: a patient safety incident, a safety barrier, and a medication error. A patient safety incident is an incident which has led or could have led to harm for the patient. A safety barrier is a structure built into the medication use process, and it is designed to improve medication safety. A medication error is a deviation from the medication process. The medication safety of cancer patients is especially important. Chemotherapeutic agents usually have a narrow therapeutic index and they have toxic side effects even in therapeutic doses. Accordingly, chemotherapeutic agents are classified as high alert medications. This means that they have an increased risk for patient harm if used improperly. Cancer patients are often elderly people and they have comorbid diseases. As a result, they are more susceptible to adverse drug effects. Moreover, the use of anticancer drugs varies between patients and the different indications of a drug, and supportive therapies are often needed. Thus, cancer pharmacotherapy is complicated. In this registry study, safety in the medication process of cancer treatment was studied using voluntary patient safety incident reports in one university hospital district in Finland. The aim of this study was to describe medication errors in cancer treatment, and safety barriers in the medication use process. The reported medication safety incidents were analysed by combining quantitative and qualitative methods. Altogether 176 incident reports were analysed relating to the use of anticancer drugs and supportive therapies. The most common medication errors were administration (27 %), prescribing (11 %), and ordering errors (10 %). These medication errors were typically omission errors. There were safety barriers in the medication process, such as double-checking of medicines, but they were not always fully effective. Some barriers were missing, for example, computer programs lacked important safety features. Safety barriers are needed, and should be further developed especially in the prescribing, ordering and administration phases of the process. More effective barriers would increase patient and medication safety in cancer treatment. The classification of medication errors in patient safety incidents was not always correct. Therefore, reporting and analysing of reports should be improved. The results of this study can be utilised for improving medication safety in all organisations giving cancer pharmacotherapy.
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(2014)The role of community pharmacy is to ensure and promote medication safety in treatment of outpatients. In Finland a national four-year medication safety program Apila was launched in 2012. The Apila program aims to improve medication safety with pharmaceutical counselling and followup, support development and implementation of new tools and practices promoting medication safety, increase awareness of medication safety as part of patient safety and increase co-operation between community pharmacies and other social- and healthcare services. The objective of this study was to investigate medication safety situation of Finnish pharmacies in the beginning of Apila program. Research data was collected electronically at the end of 2012 by using a two structured survey instruments. Target of the study was the whole pharmaceutical staff of Finnish community pharmacies. There were two separated study samples. Survey instruments were alike for both samples with the exception of one section. One survey was sent to all independent pharmacy owners (n=593) and managers of university pharmacies (n=18). The other survey was sent to one member of pharmaceutical staff in every community pharmacy (n=618) and university pharmacies (n=17). The response-rate of pharmacy owners (O) was 39 % (n=241) and response-rate of pharmaceutical staff (S) was 29 % (n=182). Representativeness of data was good compared to standard population. According to study the barriers built into the dispensing process worked well. Verifying dose (O: 100 %, S: 98 %), interactions (O: 97 %, S: 94 %) and duplicated medications (O: 79 %, S: 70 %) was a common part of dispensing process. Over half of pharmacies had a written standard operating procedure to medication counselling given when dispensing prescribed (O: 74 %, S: 60 %) and over the counter medicines (O: 60 %, S: 60 %). About 90 % of the pharmacies had a standard operating procedure to reporting and managing dispensing errors (O: 92 %, S: 84 %). According to almost all respondents (O: 96 %, S: 91 %) medication errors were reported in their workplace. Though discussing dispensing errors with whole staff (O: 73 %, S: 53 %) and changing course of action after managing dispensing errors (O: 85 %, S: 63 %) was not as common. The respondents were of the opinion that pharmacy had closer co-operation with home care and social services than with health care services. Some pharmacies had agreed with local healthcare how to manage interactions (O: 39 %, S: 23 %), contraindications (O: 36 %, S: 19 %) and prescribing errors (O: 28 %, S: 15 %) discovered in pharmacy. The study indicates that Finnish community pharmacies have good abilities to identify medication related problems. Co-operation between community pharmacies and other social- and health care services should be promoted, because it seems to be superficial. The biggest challenges in risk management are complete invocation of data collected through error reporting and including medication safety audits into quality management. Pharmacy owners' answers to the questionnaire were more positive than staff members', which indicates that actions to promote medication safety should be made more visible. Coordination of medication safety should be emphasized both national and individual pharmacy level. Low response-rates weaken the reliability of the study, but the results are suggestive.
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(2016)Medication safety meaning the safety of using medication is an important part of patient safety. Medication errors are the most common preventable threats of patient safety. Medication errors can occur in all stages of the medication process. Rather than blaming individuals involved in the process, incidents should be evaluated based on system thinking with an aim of identifying system and process-based weaknesses allowing errors to happen. James Reason's human error theory provides a good framework to investigate the topic from this perspective. The objective of this study was to gather information on the medication errors based on the Patient Insurance Centre 2013-2014 data of compensated medication errors. One of the aims was to identify different types of medication errors and gather information on their backgrounds and drugs involved. Another aim was to investigate the causes behind the medication errors and the views of the people involved on the contributin factors of these errors. Additionally the study aimed at identifying situations where interprofessional collaboration could have prevented medication errors from occurring. Finally the results of the study were also compared with the results of the earlier studies done using similar data. The data of the study consisted of 205 cases where medication error had caused compensated patient injury. Factors behind the errors were analyzed using descriptive statistics. The examples of most common cases were investigated more in depth through simplified root-cause analysis. Content analyses were used to gather information on the views of the people involved in errors as well as on the possibilities of preventing errors through interprofessional collaboration. The most frequent error type was omission of medication. The majority of the errors occurred in the early stages of the process when decisions on medication and treatment were done. There were altogether 250 drugs in the data out of which 98 different active ingredients were identified. Antithrombotic agents were the most common therapeutic group causing medication errors. 37% of all drugs included in data were classified as high alert medicines. More efficient use of the interprofessional collaboration could have prevented several medication errors. The number of medication errors had somewhat increased compared to earlier studies but the profiles of errors were very similar. The data of Patient Insurance Centre provides valuable information on medication errors across Finland. More accurate information on factors leading to medication errors could be obtained by improving voluntary nationwide reporting. This would make it easier to develop operating models that improve patient safety.
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(2019)Medication safety is a part of patient safety, and means safety related to the use of medicines. Medication safety covers the principles and functions of individuals and organizations working in the healthcare sector to ensure the safety of drug treatment and to protects patient from harm. Medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer. Medication errors are the leading cause of preventable harm in health care across the world. Therefore, improving medication safety is important from the point of view of the promotion of patient safety. The aim of this study was to gather information about serious medication errors at national level by utilizing data from Valvira to learn from the cases outside the organizations where they occurred. The data of this study consisted of complaints and regulatory statements resolved by Valvira in 2013–2017, in which drug treatment were identified as a main reason and where inappropriateness was found (n=58). Cases were classified with predetermined classification system, and inductive content analysis was used to identify the causes and contributing factors of medication errors. The theoretical framework of the study was the Human Error Theory by James Reason (1990). According its systems-based approach, this study focused on the processes and circumstances of organizations. Of the included 58 cases, medication errors caused patient’s death in 21 cases (36 %) and severe harm in nine cases (16 %). A majority (n=53; 91%) of the errors were estimated to be either definitely or possibly preventable. Most of the patients were older adults (mean age 74 years). The most commonly related drugs in medication errors were enoxaparin (n=7; 6%) and oxycodone (n=7; 6%). The most common therapeutic group causing medication errors was antithrombotic agents (n=17; 13%). Most errors occurred in hospital settings (n=29; 45%) and in elderly care units. Doctors (n=37; 50%) were most often involved in the errors. Most of the medication errors occurred in the prescribing (n=38; 47%), administrating (n=15; 19%) and monitoring stage (n=14; 17%), drug-related problems being most often connected to the drug selection. In severe and fatal cases, there are often several drug related problems identified at different stages of the patient’s drug treatment process. The data of Valvira provide valuable information about medication errors at national level. Qualitative analysis is important especially for learning purposes as it provides better understanding of the causes and contributing factors of medication errors, as well as the complexity of drug treatment processes. Based on this study, it seems that healthcare organizations involved in severe medication error cases have taken into consideration the importance of process development and focused on identifying latent risks in organizational conditions and processes rather than blaming individuals.
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