Some 22,863 medication incidents were reported by HSE services in a 30-month period, according to data obtained by the Medical Independent under Freedom of Information (FoI) law. Over 21,000 were ‘near miss’ or ‘no harm’ incidents.
A medication incident is any preventable event that may cause or lead to inappropriate medication use or patient harm.
The FoI data, covering 1 January 2022 to 30 June 2024, was extracted from the National Incident Management System (NIMS). It does not include incidents in voluntary organisations.
In 2023 some 9,540 incidents were reported. This compared with 8,652 in 2022. Some 4,671 incidents occurred in the first half of 2024.
Overall, the data included more than 20 ‘category one’ incidents resulting in long-term disability or incapacity including psychosocial incapacity (11 in 2022; nine in 2023; and <5 in the first six months of 2024).
The HSE did not release specific figures on the number of deaths. There were between one and five deaths in 2022; none in 2023; and between one and five deaths in the first half of 2024.
There were 549 ‘category two’ incidents that caused harm requiring medical treatment.
The ‘category three’ data included 500 incidents of harm requiring first aid and 713 incidents of harm which did not require first aid.
According to the HSE Incident Management Framework, a patient safety incident includes ‘harm’, ‘no harm’, and ‘near miss’ events.
A ‘near miss’ is an incident that was prevented “due to timely intervention or chance” and where there were reasonable grounds to believe it could have resulted in “unintended or unanticipated” harm/injury to a service-user.
A ‘no harm’ incident is one where harm/injury was avoided by chance or mitigating circumstances.
Healthcare staff are encouraged to report all incidents to the NIMS to enable learning and improvements across the system.
An analysis by the State Claims Agency (SCA), published last year, found the most common medication incident category was ‘omitted/delayed dose’.
Antithrombotic agents were the subgroup of medications most commonly involved in incidents, according to the analysis of NIMS data from 2019 to 2022.
One-in-10 medication incidents were reported without the name of the medication(s) involved. ‘Administration’ and ‘prescribing’ accounted for most incidents by stage of process.
Only 3.9 per cent of incidents were reported by doctors, which indicated this was an “area for improvement”. Some 45.2 per cent of incidents were reported by nursing/midwifery staff and 41.6 per cent by ‘allied health professionals’.
According to the World Health Organisation, harm due to medicines and therapeutic options accounts for nearly 50 per cent of preventable harm in medical care. Weak medication systems and/or human factors such as fatigue, burnout, poor environmental conditions, or staff shortages, are among the contributory factors.
We require electronic prescribing to help reduce prescribing error!