Sammanfattning
Background: Annually several deaths and serious injuries in hospitals are caused by medication
errors. The extent of harm caused by medication error in primary care is however not well studied (1).
The aim of this study was to analyze medication errors in home care services and to provide input
for better medication management and patient safety.
Method: Review of reported medication errors. Overt observational study of medication management
and administration in patients’ homes by shadowing health care workers on duty.
Results: 84 of 122 errors reported from home care workers in one municipality, were related to
medicines management. Omissions were most commonly reported, mainly caused by poor routines
or failing to read the work list(s). During visits, observations revealed that oral administrations
mainly followed protocol (89% of the observations). Contrastingly, 30% and 25% of the observations
identified deviations during inhalation and administration of eye drops, respectively.
Conclusion: A lack of knowledge about administering some types of formulations were uncovered.
The potential benefits of an established reporting system were not fully exploited. Inputs on how to
improve the current practices, were given.