High-risk medications identified from the Danish Patient Safety Database and the challenge of dissemination

Abstract

Since 2004, patient safety incidents in Denmark have been reported to a national patient safety reporting system – the Danish Patient Safety Database. The goal of the system is to improve patient safety. In 2011, a decision was made to develop a national list of high-risk medications based on the medication incidents reported to the Danish Patient Safety Database. The high-risk medications are defined as medications that have been involved in medication errors and have caused harm to patients. The purpose is to identify medications that posed a particular and preventable risk for patients. It became clear through updates that there was a group of medications that caused severe harm to the patients more frequently than others. Based on the list, the Danish Patient Safety Authority in 2015 identified seven groups of medications that require special attention from healthcare staff: antidiabetic medications, anticoagulants, low-dose methotrexate, concentrated potassium, opioids, gentamicin and digoxin. Better handling of these seven types of medication could improve patient safety significantly. For many years, Danish Patient Safety Authority has distributed tables and booklets about these high-risk medications. In addition, ‘patient safety warnings’ are issued when it is considered necessary. In spite of this, many patient safety incidents involving these medications still occur. This points to the fact that disseminating knowledge from a government level all the way to frontline healthcare staff poses a challenge. On that background, Danish Patient Safety Authority is exploring new ways to disseminate knowledge to frontline healthcare staff about patient safety incidents.