In the field of health care services adverse drug events occur repetitively through errors in the medication process. These adverse events may pose an enormous health risk to patients and cause considerable additional costs due to possible longer hospitalisation of patients. The distribution of errors also impact the development of supporting measures and the process itself. A few suggestions of medication processes are available in the literature but currently no standardized medication process is obligatory defined to ensure a uniform application in Styrian hospitals. For this reason, a literature review was conducted and a questionnaire was developed to compare results from the literature with the current medication process in Styrian hospitals.
In the literature different interpretations of the medication processes have been presented (see , ). However, four general steps were identified in each defined process (see Figure 1). Therefore this general approach was included in the questionnaire to be compared with the implemented processes in the hospitals.
In course of the literature review no data for adverse drug events (ADEs) or medication errors (MEs) in Austria were found. Results of a study in the USA  showed that the most ADEs occurred during the first and last phase of the medication process (see Figure 2). It was mentioned that 39% of all ADEs arose during the prescribing of drugs, whereas 38% appeared in the administration phase. A further investigation of the results  demonstrated that the most errors were caused by false or missing information. This clearly indicates the potential for reducing errors with regard to a well-defined medication process.
To collect more information about the current medication processes in Styrian hospitals, a questionnaire was developed. First a mind map with different blocks of the possible content was delineated for preparing the questionnaire. Based on this mind map a first version of the questionnaire was created, which was primarily tested with regard to the length of the query and the way of proceeding. Then a pre-test with six persons from different fields in medicine or biomedical research was conducted. It showed that no abbreviations should be used, some questions need to be simplified and some definitions need to be added to assist the interviewee. For this purpose, a glossary was added at the end of the questionnaire. The final test was performed with three experts from different hospitals. Two medical doctors and one nurse were selected. This final assessment showed that some further definitions and a hint to the glossary further improve the quality and validity of the questionnaire. Thus, in total three pre-tests were carried out, before the questionnaire was finalized and ready to be used for the survey.
The final version of the questionnaire comprises 29 questions where four of them are open and 25 closed questions. The content was divided into four different parts (Part A to D). Part A includes questions regarding the realisation of the medication process in the hospital. Part B refers to questions associated to possible guidelines, which are used or affect the applied procedure in the hospital. Part C deals with medication errors and their report as well as their probability of occurrence. The last part covers the field of organizational, personnel and technical solutions for reducing errors in the medication process. Additional questions were supplemented in part D, referring to possible solutions and their implementation in the daily routine.
The final version of questionnaire comprises seven A4 pages where the first page contains an introduction with contact details, and the last page a glossary of definitions. It takes approximately 10–15 min to fill out all questions, depending on the details given in the open questions.
For the survey all 37 Styrian hospitals were requested and 11 of them filled out the questionnaire. The hospitals were contacted either by phone or e-mail. The hospitals had the opportunity to fill out the form face-to-face or to send it back by e-mail or regular mail.
The questionnaire was returned from 11 hospitals, which represents a response rate of 29.7%.
Results of Part A showed that in only five of 11 cases a specific medication process including predefined process stages is visualized and implemented. A closed-loop process is ensured in 73% of all hospitals. A standardized process is considered as useful and would be accepted in all hospitals. This process should be available as desired via guideline (82%) or implemented in the quality management system (55%).
The results of part B demonstrated that in all hospitals guidelines are used to support the medication process and internal guidelines from the hospital management are primarily used.
The evaluation of questions of part C makes clear that the control of medication errors is considered as extremely important in all hospitals. About 80% of all responders consider the report and record of MEs as significant. However, in only 64% of the cases MEs are currently recorded. In most cases they are reported by hand and not automatically through technical solutions.
From results of part D it can be concluded that a large number of technical solutions are considered as useful in the majority of hospitals (see Figure 3). But with exception of CIRS other technical measures are marginally intended or implemented yet.
The results of the question regarding organizational solutions are shown in Table 1. A lot of organizational measures have already been implemented and in addition also new solutions (17 intended measures) are planned in Styrian hospitals.
Results of the evaluation of question 2 regarding organizational measures to support the medication process in Styrian hospitals (part D).
|Organizational measures||Adequate no. (%)||Intended no. (%)||Implemented no. (%)|
|Process analysis||11 (100)||2 (18)||7 (64)|
|Restrictive drug assortment||11 (100)||0 (0)||10 (91)|
|Avoiding media disruption||10 (91)||5 (45)||3 (27)|
|Management on interfaces||11 (100)||4 (36)||5 (45)|
|Double checking||11 (100)||1 (9)||8 (73)|
|Global standardization||11 (100)||1 (9)||8 (73)|
|Collection of adverse effects||9 (9)||1 (9)||2 (18)|
|Access controls||10 (91)||1 (9)||7 (64)|
|Operating instructions||10 (91)||0 (0)||10 (91)|
|Use of evidence based medicine||11 (100)||2 (18)||8 (73)|
The analysis of the questionnaire showed that no standardized medication process exists so far, but most of the responders consider a standardized process as useful. This generally defined process would be helpful for analysing errors in each stage of the medication process. Furthermore this would help to improve existing solutions and to develop new measures to reduce the error rate. Such a general process would also enable benchmarking between hospitals.
Personnel and organizational solutions for reducing the error rate are assessed as useful and widely implemented in the Styrian hospitals. Technical measures on the other hand are considered as appropriate, but with exception of the critical incidence reporting system, they are barely implemented in hospitals so far. However, new technical solutions (e.g. unit dose systems or electronical control systems like RFID scanning) could support the medication process. This would lead to a higher patient safety during the entire drug therapy. Leape et al. concluded  that most of the errors occur in the phases of prescribing and administration. The number of these errors could be drastically reduced by using technical solutions like computerized physician order entry (CPOE) or scanning systems.
In addition it was found out that the probability of adverse drug events (ADEs) estimated from the responders do not match with results from the literature. The numbers are widely underestimated. Whereas Leape et al.  showed that 334 ADEs occurred in a period of only 6 months, results gathered from the questionnaire show a range of only 15–100 ADEs per year estimated in Styrian hospitals. This reveals out of the error reporting culture in health care, which is obvious not satisfactory.
The incidence of ADEs and MEs influence the development of a standardized medication process. The literature showed that some stages can be combined (e.g. prescribing – transcription) and new stages (e.g. to inform the patient or monitoring and result evaluation) could be added in the process. Furthermore authors suggest a standardized process structure which should match to error reducing measurements (e.g. Bar Code Scanning) .
In conclusion the evaluation of the questionnaire presents a general overview of the current status of the medication process in Styrian hospitals and further improvements and new solutions can be derived from these basic findings.
Research funding: The author state no funding involved. Conflict of interest: Authors state no conflict of interest. Material and methods: Informed consent: Informed consent is not applicable. Ethical approval: The conducted research is not related to either human or animal use.
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