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Medication Safety, v3
Medication errors resulting in an adverse event
CI 2.1: Medication errors – adverse event requiring intervention (L)
Rationale
The use of medication remains the most common intervention in health care. Medicine misuse,
underuse or over use and adverse reactions annually result in an estimated 140,000 annual
hospital admissions in Australia; most of these adverse drug events are preventable.
Numerator
Denominator
Total number of medication errors resulting in an adverse event requiring intervention
beyond routine observation and monitoring
Total number of occupied bed days
Year
Dimensions of care: Accessibility Appropriateness Continuity
Effectiveness Quality Improvement and Risk Safety
Desirable level: Low High Not specified
Type of Indicator: Process Outcome Structure
No.
HCOs
Total
numerator
Total
denominator
Rate #
Rate#
(20)
Rate #
(80)
Centile
Gains
Stratum
Gains
Outlier
Gains
2005 144 400 3,867,458 0.010 0.002 0.014 314 161
2006 203 1,394 6,392,952 0.022 0.002 0.016 1,239 497 758
2007 259 6,580 8,263,636 0.080 0.003 0.087 6,364 3,642 3,781
2008 267 5,185 9,484,850 0.055 0.002 0.039 4,955 3,246
2009 259 3,949 9,339,048 0.042 0.002 0.021 3,771 2,562
2010 262 2,211 9,425,487 0.023 0.001 0.015 2,082 1,328
2011 247 892 7,132,050 0.013 0.003 0.014 712 331
#per 100 bed days
In 2011 there were 420 submissions from 247 HCOs. The annual rate was 0.013 per 100 bed
days.
Trends
The fitted rate improved from 0.051 to 0.030, a change of 0.021 per 100 bed days. This trend
was also significant after allowing for the changing composition of HCOs contributing over the
period. The rate change was 0.020 per 100 bed days.
Rates and centiles by year
A Low rate is desirable
80 th centile rate
x
Aggregate rate
Period average rate
Fitted rate
20 th centile rate
Australasian Clinical Indicator Report 2004–2011 Page 3
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