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other·patient safety, pharmacology, geriatrics, general practice, cardiology, endocrinology, neurology, psychiatry·PMC10026140

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study

Therapeutic Advances in Drug Safety · 4 authors, 6 centres

AI SUMMARY

FIDELITY 100%

POPULATIONPatients in England and Wales who experienced medication-related patient safety incidents following hospital discharge, reported to the NRLS between 2015 and 2019

INTERVENTIONNot applicable (retrospective analysis of incident reports)

COMPARISONNot applicable

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AGENT 01 · STRUCTURED SUMMARY

TRACE TO SOURCE

“

TL;DR

This multi-method study analyzed 1,121 medication safety incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019 following hospital discharge. Over half of incidents involved patients aged >65 years, and more than one in ten (12.6%) were associated with patient harm, with drug monitoring and administration stages carrying the highest proportion of harmful incidents. The most common contributory factors were organizational issues (82%), particularly failures in continuity of care between secondary and primary care, highlighting targets for improvement including better communication, medication monitoring, and patient engagement.

Full summary

5,040 CHARS

**Background:** The transition of care from hospital to community settings is a high-risk period for medication-related safety incidents, recognized by the WHO as a global priority for action. While existing research shows that medication errors (MEs) and adverse drug events (ADEs) affect up to one in two and one in five patients respectively after discharge, there is limited national-level understanding of their nature and contributory factors. This study aimed to characterize the nature and contributory factors of medication-related incidents during transition from secondary to primary care using national incident report data from England and Wales.

**Methods:** The researchers conducted a retrospective analysis of medication-related patient safety incidents reported to the National Reporting and Learning System (NRLS) between 1 January 2015 and 31 December 2019. Incidents were extracted using a free-text search for 'discharge' (including misspellings) within the 'medication' category and 'general practice' care setting. After excluding 203 of 1,324 reports (e.g., non-discharge-related, clinic discharges, duplicates), 1,121 incidents were analyzed. Descriptive analysis examined frequency and nature of incidents. Content analysis of free-text narratives was performed using the Patient Safety Research Group (PISA) classification to identify contributory factors and outcomes. Twenty percent of data (n=237) was independently coded by two researchers for validation.

**Key Results:** Most incidents involved patients aged >65 years (55%, n=626/1,121; 70.4% of reports with age data). More than one in ten incidents (12.6%, n=142/1,121) were associated with actual patient harm: low harm (5.1%, n=58), moderate harm (6.1%, n=69), severe harm (0.7%, n=8), and death (0.6%, n=7). The most common medication process stages were prescribing (42%, n=479/1,121), administration (22.5%, n=253/1,121), and monitoring (12%, n=140/1,121). The monitoring (17%) and administration (15%) stages had higher proportions of harmful incidents than prescribing (12%). The most reported error categories were wrong/unclear dose or strength (19%, n=212/1,121), omitted medicine (13%, n=148/1,121), and wrong drug/medicine (10%, n=118/1,121). Medication omission was associated with the highest proportion of harmful incidents among frequently reported error types (19%, n=28/148). A total of 1,504 medications were involved across incidents. The most common medication classes were cardiovascular (48.8%, n=734/1,504), central nervous system (18%, n=273/1,504), and endocrine (12%, n=183/1,504). Specific high-frequency medications included antiplatelets (n=126), factor Xa inhibitors (n=124), opioids (n=79), insulin (n=76), beta-blockers (n=76), heparins (n=71), vitamin K antagonists (n=67), and diuretics (n=66). Among 408 incidents (36%) with sufficient free-text data to identify contributory factors, 467 factors were coded. Organization factors were most common (82%, n=383/467), with 98% (n=377/383) related to continuity of care—primarily between secondary and primary care (n=308) and between healthcare and pharmacy (n=35). Staff factors accounted for 16% (n=75/467), including cognitive issues (47%, n=35/75) such as mistakes and misreading, and task-related issues (44%, n=33/75) including failure to follow protocol (n=14) and wrong professional carrying out the task (n=14). Patient factors (n=5) and equipment factors (n=4) were rare. Among 1,660 reported outcomes, 34% (n=564) were organizational inconvenience (mostly phone calls/follow-up, n=412), 27% (n=455) were patient inconvenience (including missed doses, n=107; unnecessary treatment, n=90; repeated visits, n=76; hospital admission, n=55), and 13% (n=216) were patient clinical harm.

**Clinical Implications:** This study identifies several actionable targets for improving medication safety after hospital discharge. The high involvement of cardiovascular and central nervous system medications suggests these should be prioritized in prescribing safety indicators and pharmaceutical prioritization tools. The predominance of organizational contributory factors—especially failures in continuity of care and information sharing between secondary care, primary care, and community pharmacies—supports the implementation of electronic interventions like the NHS Discharge Medicine Service (DMS) to improve timely communication. Staff factors, including cognitive errors and task delegation issues (e.g., administrative staff handling prescriptions), highlight the need for appropriate skill mix, such as embedding clinical pharmacists in general practices to triage discharge letters and perform medication reconciliation. The finding that patients or relatives identified errors and prevented harm in 72 incidents supports incorporating patient and family engagement into safety strategies. The association of monitored dosage systems (MDS) with errors indicates a need for further research to improve safety for patients using compliance aids post-discharge.

PICO

PPOPULATION

Patients in England and Wales who experienced medication-related patient safety incidents following hospital discharge, reported to the NRLS between 2015 and 2019

IINTERVENTION

Not applicable (retrospective analysis of incident reports)

OOUTCOME

Nature, severity, and contributory factors of medication safety incidents; 12.6% associated with actual patient harm; most common error categories were wrong/unclear dose or strength (19%) and omitted medicine (13%)

STUDY TYPE

other

SPECIALTY

patient safety

SUMMARISED BY

AI pipeline

FIDELITY CHECK

100% · A

ORIGINAL PAPER

PMC10026140

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study

Therapeutic Advances in Drug Safety

READ THE FULL PAPER

ABSTRACT

Abstract Introduction: Improving medication safety during transition of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. Aim: To characterise the nature and contributory factors of medication-related incidents during transition of care from secondary to primary care. Method: A retrospective analysis of medication incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019. Descriptive analysis identified the frequency and nature of incidents and content analysis of free text data, coded using the Patient Safety Research Group (PISA) classification, examined the contributory factors and outcome of incidents. Results: A total of 1121 medication-related incident reports underwent analysis. Most incidents involved patients over 65 years old (55%, n = 626/1121). More than one in 10 (12.6%, n = 142/1121) incidents were associated with patient harm. The drug monitoring (17%) and administration stages (15%) were associated with a higher proportion of harmful incidents than any other drug use stages. Common medication classes associated with incidents were the cardiovascular ( n = 734) and central nervous ( n = 273) systems. Among 408 incidents reporting 467 contributory factors, the most common contributory factors were organisation factors (82%, n = 383/467) (mostly related to continuity of care which is the delivery of a seamless service through integration, co-ordination, and the sharing of information between different providers), followed by staff factors (16%, n = 75/467). Conclusion: Medication incidents after hospital discharge are associated with patient harm. Several targets were identified for future research that could support the development of remedial interventions, including commonly observed medication classes, older adults, increase patient engagement, and improve shared care agreement for medication monitoring post hospital discharge. Plain language summary Study using reports about unsafe or substandard care mainly written by healthcare professionals to better understand the type and causes of medication safety problems following hospital discharge Why was the study done? The safe use of medicines after hospital discharge has been highlighted by the World Health Organization as an important target for improvement in patient care. Yet, the type of medication problems which occur, and their causes are poorly understood across England and Wales, which may hamper our efforts to create ways to improve care as they may not be based on what we know causes the problem in the first place. What did the researchers do? The research team studied medication safety incident reports collected across England and Wales over a 5-year period to better understand what kind of medication safety problems occur after hospital discharge and why they happen, so we can find ways to prevent them from happening in future. What did the researchers find? The total number of incident reports studied was 1121, and the majority ( n = 626) involved older people. More than one in ten of these incidents caused harm to patients. The most common medications involved in the medication safety incidents were for cardiovascular diseases such as high blood pressure, conditions such as mental illness, pain and neurological conditions (e.g., epilepsy) and other illnesses such as diabetes. The most common causes of these incidents were because of the organisation rules, such as information sharing, followed by staff issues, such as not following protocols, individual mistakes and not having the right skills for the task. What do the findings mean? This study has identified some important targets that can be a focus of future efforts to improve the safe use of medicines after hospital discharge. These include concentrating attention on medication for the cardiovascular and central nervous systems (e.g., via incorporating them in prescribing safety indicators and pharmaceutical prioritisation tools), staff skill mix (e.g., embedding clinical pharmacist roles at key parts of the care pathway where greatest risk is suspected), and implementation of electronic interventions to improve timely communication of medication and other information between healthcare providers. Keywords: adverse drug event, continuity of patient care, hospital discharge, incident report, medication errors, medication safety

CITATION EXPORT

Fatema A Alqenae, Douglas Steinke, Andrew Carson-Stevens et al.. Analysis of the nature and contributory factors of medication safety
incidents following hospital discharge using National Reporting and Learning
System (NRLS) data from England and Wales: a multi-method study. Therapeutic Advances in Drug Safety. (2023). https://doi.org/10.1177/20420986231154365

AUTHORS

4 · 6 CENTRES

Fatema A Alqenae, Douglas Steinke, Andrew Carson-Stevens, Richard N Keers

1Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Oxford Street, Manchester M13 9PL, UK
2Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
3Pharmacy Department, Manchester University NHS Foundation Trust, Manchester, UK
4Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
5Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, UK
6Suicide, Risk and Safety Research Unit, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK