High-risk medication errors: insight from the UK National Reporting and Learning System.
Errors involving high-risk medications have the potential to cause serious harm or death. In this study, incident reports from the UK's National Reporting and Learning System involving three high-risk medications—opioids, insulin, and anticoagulants—were analyzed to determine the nature and types of errors as well as contributing factors. Around half of errors for each type of medication occurred at administration. 97% of errors resulted in low or no harm. Despite the encouraging results, the authors note the importance of continuing to improve the quality of incident reports to yield better learning opportunities to improve medication safety.