Flow of information contributing to medication incidents in home care—An analysis considering incident reporters' perspectives

Abstract

AbstractAimTo describe the contributing factors and types of reported medication incidents in home care related to the flow of information in different phases of the medication process, as reported by multi‐professional healthcare groups.DesignThis descriptive, qualitative study used retrospective data.MethodsAn incident‐reporting database was used to collect 14,289 incident reports from 2017 to 2019 in a city in Finland. We used this data to select medication incidents (n = 1027) related to the flow of information in home care and between home care and hospitals. Data were divided into five groups based on the medication phase: (1) prescribing, (2) dispensing, (3) administration, (4) documentation and (5) self‐administration. In addition, the types of medication‐related incidents were described. The data were examined using abductive content analysis. The EQUATOR SRQR checklist was used in this report.ResultsFour main categories were identified from the data: (1) issues related to information management, (2) cooperation issues between different actors, (3) work environment and lack of resources and (4) factors related to healthcare workers. Cooperation issues contributed to medication‐related incidents during each phase. Incomplete communication was a contributing factor to medication incidents. This occurred between home care, remote care, hospital, the client and the client's relatives. Specifically, a lack of information‐sharing occurred in repatriation situations, where care transitioned between different healthcare professionals.ConclusionHealthcare professionals, organisations, clients and their relatives should focus on the efficient and safe acquisition of medications. Specifically, the use of electronic communication systems, together with oral reports and checklists for discharge situations, and timely cooperation with pharmacists should be developed to manage information flows.Relevance to Clinical PracticeThese findings demonstrate that healthcare professionals require uniform models and strategies to accurately and safely prescribe, dispense and administer medications in home care settings.No patient or public contributions.