Evidence map›Paper›PMID 39737368›Full record

ArticleExploratory research in clinical and social pharmacy2025

High-risk medication errors: Insight from the UK National Reporting and learning system.

Abdulrhman Alrowily, Khalid Alfaraidy, Saleh Almutairi, Abdullah Alamri, Wejdan Alrowily, Mohammed Abutaleb, Mohammad Zaitoun, Waddad Sarawi, Mashael Aljead

Abstract read
In one paragraph

Article in Exploratory research in clinical and social pharmacy, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 3 papers.

0numbers the graph read from it
0cells of the map it votes in
3citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

3 citing papers in PubMed.

  1. Review
  2. Article
  3. 'Why, Can I Not Have Control of My Own Insulin?': Qualitative Exploration Amongst Older Adults With Diabetes With Lived Experience of Surgical Hospital Admission.Health expectations : an international journal of public participation in health care and health policy · 2025
    Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

9 authors.

Abdulrhman AlrowilyKing Fahad Military Medical Complex, Dhahran 31932, Saudi Arabia.
Khalid AlfaraidyKing Fahad Military Medical Complex, Dhahran 31932, Saudi Arabia.
Saleh AlmutairiKing Fahad Military Medical Complex, Dhahran 31932, Saudi Arabia.
Abdullah AlamriKing Fahad Military Medical Complex, Dhahran 31932, Saudi Arabia.
Wejdan AlrowilyKing Fahad Military Medical Complex, Dhahran 31932, Saudi Arabia.
Mohammed AbutalebKing Fahd Central Hospital, Jazan 82666, Saudi Arabia.
Mohammad ZaitounArmed Forces Hospitals Southern Region, Khamis Mushait 62413, Saudi Arabia.
Waddad SarawiKing Saud University, Riyadh 145111, Saudi Arabia.
Mashael AljeadPrince Sultan Military Medical City, Riyadh 11159, Saudi Arabia.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

Background: Ensuring patient safety is of paramount importance in healthcare systems. Rising concerns about medical errors in the UK have necessitated a greater focus on studying the nature of such errors, particularly those involving high-risk medications. Objectives: To conduct a retrospective analysis of incidents related to patient safety in the UK based on data from the National Rporting and Learning System (NRLS). Methods: This study was conducted based on a review of the National Reporting and Learning System Results: The results showed that the insulin category had both the highest risk and most errors compared with anticoagulants and opioids. These errors primarily result from issues related to administering, prescribing, and dispensing the drugs. Inadequate drug checks, communication difficulties among staff and patients, and high staff workloads are often linked to these errors. Conclusion: This study confirms that the NRLS database is a valuable source of data, and the suggestions put forth, based on these results, could contribute to the formulation of measures that diminish the occurrence of errors related to high-risk drugs in healthcare settings. Information technology should enhance medication safety by tracking the process of medication use.

Indexed as

AnticoagulantsClinical pharmacologyDrug safetyInsulinMedication errorsOpioids

Identifiers

PMID39737368
PMCPMC11683304

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Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.