Emergency services are among the areas with the highest prevalence of preventable adverse drug events, according to a recent report by the World Health Organization1. Various factors converge in these settings, creating a high risk of medication errors that may lead to adverse events for patients. Emergency services attend diverse types of patients presenting with a variety of conditions, often requiring the use of high-risk medications. Besides, healthcare professionals may not always have access to the patient's complete medical history; medications are generally administered at the point of care without pharmaceutical validation; there is a higher prevalence of verbal orders, particularly in urgent and high-stress situations; and physicians and nursing staff often treat multiple patients simultaneously, facing intense care pressure, frequent interruptions, etc.2,3

Medication errors in emergency services occur more frequently during the prescribing and administration processes, although they also happen in other processes, such as in care transitions, where errors have increased in recent decades, likely because the patients who come to these services are increasingly complex and take multiple medications3–7. The prevalence of preventable adverse drug events in emergency departments ranges from 2% to 12%8. In Spain, the EVADUR study showed that 12% of patients treated in these departments experienced some type of incident or adverse event related to their healthcare, of which 24.1% were related to medications9. To reduce errors and preventable adverse drug events, emergency services need to understand the etiology of these errors and establish effective safety practices in their processes, focusing on the points most prone to errors.

The Institute for Safe Medication Practices (ISMP) in the USA has developed several Medication Safety Self-Assessments© for different settings10. These questionnaires systematically outline the safe practices that, according to available evidence and ISMP's experience in error analysis, should be implemented in relevant settings to reduce risks in their processes. They serve as a proactive tool for improving safety, helping professionals assess the implementation of safe medication practices in their systems and identify and prioritiz improvement practices to minimize the risk of medication errors. Various organizations and scientific societies have recommended their use11,12.

In Spain, the Ministry of Health and ISMP-Spain published in 2007 the ‘Medication Use Safety Self-Assessment Questionnaire for Hospitals13, which is an adaptation of the Medication Safety Self-Assessment for Hospitals© to Spanish healthcare practice, and was updated in 201814. Based on this document, ISMP-Spain, the Redfaster Working Group of the Spanish Society of Hospital Pharmacy (SEFH), and the Spanish Society of Emergency Medicine (SEMES) developed the ‘Medication Safety Self-Assessment Questionnaire for Emergency Services‘,considering the distinctive characteristics of these services and the etiology of the most common types of errors15. This specific questionnaire is useful at the local level to help professionals become familiar with safe practices, identify high-risk areas, and establish programs to improve medication safety.

Once this tool was available, the present study was undertaken for the purpose of evaluating the implementation of safe medication practices in emergency departments at the national level and identifying high-risk areas and the safety challenges that these services face and, from there, planning collaborative improvement initiatives.

This is a multicenter descriptive study conducted to assess the implementation of safety practices as outlined in the ‘Medication Use Safety Self-Assessment for Emergency Services’ questionnaire. The option to participate in the study was offered to all emergency services that completed the questionnaire within a predetermined period (from May 16, 2023 to November 16, 2023).

The study was distributed by SEFH and SEMES to their members via their email distribution lists. Participating services were instructed to create an interdisciplinary team to carry out the evaluation, and were provided with a password to access a software application for recording their responses. This application, hosted on the ISMP-Spain website, ensures data confidentiality.

By the end of the study, 72 emergency services had completed the questionnaire, 71 from 12 Spanish autonomous communities and 1 from Andorra. Table 1 shows their characteristics. Of the 72 participating emergency services, 68 were general and 4 were pediatric.

Table 2 shows the results obtained for the entire questionnaire in the 72 emergency departments and in the different groups established based on the characteristics considered. The mean score for the entire questionnaire in the total sample was 428.3 points, corresponding to 51.1% of the maximum possible score (838 points). A large variation was observed in the scores obtained by the different participating emergency departments, ranging from 164 to 620.5 points. No statistically significant differences were found between the percentages of the maximum possible scores obtained among the different groups established.

Fig. 1 shows the results for the key elements expressed as a percentage of the maximum possible score, allowing for comparison and identification of the areas of greatest risk. Four key elements scored less than 50%: element VIII on competency and training of healthcare professionals in safety practices (38.4%); element III on incorporating pharmacists into emergency services (42.1%); element I on availability and accessibility of essential patient and drug information (43.1%); and element IX on patient or family education (48.1%). The remaining key elements scored close to or more than 50%. The highest scores were for element IV on drug labeling, packaging, and naming (69.2%) and element II on communication of prescriptions and other drug information (64%).

Fig. 1.

Results from the 72 emergency services expressed as percentages of the maximum possible score by the 10 key elements and for the complete questionnaire.

Abbreviated description of the key elements: I. Availability and accessibility of patient and drug information. II. Communication of prescriptions and other drug information. III. Incorporation of pharmacists into emergency service teams. IV. Drug labelling, packaging, and naming. V. Drug standardization, storage, and distribution. VI. Medication device acquisition, use, and monitoring. VII. Environmental factors and human resources. VIII. Staff competency and training in medications and safety practices. IX. Patient or family education. X. Quality processes and risk management.

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Table 3 presents the results expressed as a percentage of the maximum possible scores for the 10 key elements in the totality of emergency services, as well as in the groups categorized by the hospital's functional dependency and size, type of emergency service, and teaching activity. No statistically significant differences were found between public or private hospitals, number of beds, type of service, or teaching activity, except for key element III corresponding to the incorporation of pharmacists in emergency services. In this case, statistically significant differences (p = .008) were observed between hospitals with less than 200 beds (28.9%) and those with more than 500 beds (52.2%).

Table 4 includes the results for specific items corresponding to several safety practices recommended for implementation in emergency services, considering the processes most prone to errors and associated elevated risk factors.3,7,16 These practices include the following: accessibility to the patient's medical records; electronic prescribing systems with clinical decision-support; the establishment of a safe procedure for repeating verbal orders; incorporation of pharmacists in emergency care teams; the implementation of safe practices for high-risk medications, including the protocolization and standardization of intravenous solution concentrations, and the use of smart infusion pumps; barcode scanning in medication administration; medication reconciliation during care transitions; professional training, and analysis and learning from errors. Most of these items showed low implementation percentages, below or close to 50%, particularly the use of barcodes in administration (10.2%); the provision of information about high-risk medications to patients at discharge (14.8%); the use of smart infusion pumps (38%); and the availability of an integrated medical record (39.5%). Practices related to medication reconciliation such as obtaining a complete pharmacotherapeutic history (37.7%) and reconciling medications when discharging patients from the emergency department to their homes, also showed low implementation (38.5%).

Emergency departments are environments with a high risk of medication errors. To minimize these errors, effective safe practices should be implemented in each and every process of the medication use system.

This study provides information on the current state of implementation of safety practices in the emergency departments of our hospitals, and highlights that there are numerous opportunities for improvement. The mean score for the entire questionnaire was 51.1%, with marked differences between participating services, showing values ranging from 19.6% to 74.1%. It should be noted, however, that the practices included in the questionnaire are not minimum safety standards, but rather, effective measures that emergency services should aim to implement to prevent errors; examples include barcode scanning during drug administration17 and double-checking before administration18.

To our knowledge, there are no similar studies conducted specifically in emergency departments with which the results can be directly compared. However, it is worth mentioning that the observed results are largely consistent with those of the latest study on the implementation of safety practices in Spanish hospitals, conducted in 2022 at 131 centers, using the general hospital questionnaire19. Although these studies are not entirely comparable as the hospital questionnaire is much broader and element III does not correspond, in both studies, the highest values were observed for the key elements related to medication labeling, packaging, and naming (69.2%) and the communication of prescriptions and other medication information (64%). Similarly, the elements with the lowest percentages in both studies were element VIII, related to the competency and training of professionals in medications and safe practices, and element I, concerning the availability of patient information. There is no doubt that these are areas in which the collaborative group from SEFH and SEMES will need to work together to promote the implementation of safe practices. In fact, training in safety within emergency departments has been established by both societies as one of the basic collaborative functions to be developed 20.

When comparing the results of this emergency department study with the general hospital study, it is also noteworthy that the scores obtained for most key elements in emergency departments were generally lower, particularly for element IX on patient education (48.1% vs 58%). Establishing appropriate education programs, though a recommended practice, is hindered by high patient turnover, rushed discharges to free up beds in emergency departments, heavy professional workload, and limited staffing.

The incorporation of clinical pharmacists into emergency care teams is one of the measures that has been shown to have the greatest impact on reducing medication errors in emergency departments21,22. For this reason, several scientific societies of emergency professionals consider it an essential aspect in their units20,23. The low score obtained in this element of the questionnaire requires a strong commitment to incorporating clinical pharmacists as one of the first and foremost steps needed to improve safety in these settings, especially in smaller hospitals, where the questionnaire results show a lower participation of pharmacy services.

The study has several limitations derived from the methodology used. The sample may not be representative of all the emergency departments, as it was not randomly assigned, and, in fact, the services that voluntarily chose to participate in the study might be more aware of medication error prevention, which could have introduced bias in the results. Another aspect limiting the results relates to the completion of the questionnaire. Although the instructions for self-assessment indicate that it should be carried out by a multidisciplinary team familiar with the reality of the emergency department, no control was implemented to verify this. Finally, another limitation to note, inherent to this type of self-assessment tool, is the potential variability in how different items of the questionnaire are interpreted by the teams in each department, which could affect the results.

In summary, this study should promote self-assessment for safe medication practices in emergency services, allowing professionals to understand the degree of implementation in their specific departments and to drive interventions for improvement. Furthermore, the present study has identified several safety practices that are insufficiently implemented in emergency departments across the country, highlighting areas for improvement where planning collaborative initiatives to minimize medication errors in patients treated in these units should be a priority.

This study provides detailed information on the safety of the medication use systems in emergency departments and quantifies the degree of implementation of safe practices considered essential to avoid the most common errors in this area.

Understanding the highest-risk points in the processes will be highly useful for planning collaborative improvement initiatives among emergency departments.

The present study was supported by the Spanish Society of Hospital Pharmacy (SEFH).

Andalusia: M.A. Castro Vida (Hospital Universitario de Poniente, El Ejido, Almería); I. Vallejo Rodríguez (Hospital Universitario San Cecilio, Granada); A. Sánchez Martín, F. Alonso Morales (SU General, Hospital Universitario Virgen de las Nieves, Granada); E. González del Valle, C. González Hervás (SU Pediátrico, Hospital Universitario Virgen de las Nieves, Granada); V. Faus Felipe (Hospital Costa del Sol, Marbella, Málaga); M.T. Serrato Llamas (Hospital Serranía de Ronda, Ronda, Málaga); A. Fernández de Simón Almela, D. Avilés (SU General, Hospital Universitario Virgen del Rocío, Sevilla); C. Álvarez del Vayo, M.J. Sánchez Álvarez (SU Pediátrico, Hospital Universitario Virgen del Rocío, Sevilla).

Aragon: F. Glave Royo, C. López Más (Hospital Obispo Polanco, Teruel); I. Navarro Pardo, M. Arenere Mendoza (Hospital Universitario Lozano Blesa, Zaragoza); J.M. Real Campaña, F.J. Abellán Antolín (SU General, Hospital Universitario Miguel Servet, Zaragoza); V. Gómez Barrena (SU Pediátrico, Hospital Universitario Miguel Servet, Zaragoza); J. Sánchez Melús, M.L. Catalán Ladrón (Hospital Ernest Lluch, Calatayud, Zaragoza).

Asturias: N. Pérez Domínguez, M. Albuerne Sergas (Hospital Universitario San Agustín, Avilés); C. Orallo Luna, C. Calzón Blanco (Hospital Universitario Central de Asturias, Oviedo).

Balearic Islands: J. Martínez Sotelo, F.J. Rodríguez Segura (Hospital de Inca, Mallorca); M. Vilanova Boltó; B. Calderón Herranz (Hospital Universitario Son Llatzer, Palma de Mallorca); M. Prats Riera, A.B. Berzosa Ortega (Hospital Can Misses, Ibiza).

Castile-La Mancha: M.R. Ortiz Navarro (Hospital Universitario de Albacete); E. Palacios Moya, A. Sánchez Cadena (Hospital General Universitario de Ciudad Real).

Castile and León: A.M. López González, J. García Criado (Hospital Universitario de Salamanca); J.A. Jodra Pérez, M.E. Fernández García (Complejo Asistencial de Soria).

Catalonia: J. Martínez Casanova, A. Suarez-Lledó (Hospital Universitari de Bellvitge, Barcelona); J. Ruiz Ramos, M.T. Álvarez Arranz (Hospital de la Santa Creu i Sant Pau, Barcelona); R. López Martínez, M. Arranz Betegón (Hospital Universitari Vall d'Hebrón, Barcelona); A. Ayestarán Altuna, J. Fierro Banzo (SCIAS Hospital de Barcelona); J. Barceló Vidal, I. Cirera Lorenzo (Hospital del Mar, Barcelona); G. García Segarra, N. Pons Llobet (Hospital Universitari Sagrat Cor, Barcelona); V. de Dios Benito, A. Martín Val (Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona); G. Zapata González, A. M. Armero Garrigos (Corporació de Salut del Maresme i la Selva, Calella, Barcelona); V. Arias Constantí, M. Duero Adrados (Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona); T. Baeza Ransanz, P. Alonso Castell (Fundación Althaia de Manresa, Barcelona); Y. Campos Baeta (Hospital Sant Joan de Déu, Martorell, Barcelona); J. Ramos Rodríguez, C. Netto Miranda (Hospital Universitari Parc Taulí, Sabadell, Barcelona); L. Val Prat, P. Amorós Reboredo (Hospital General de Catalunya, San Cugat del Vallés, Barcelona); G. Garreta Fontelles (Hospital Universitari Mútua de Terrassa, Barcelona); A. Pérez Plasencia, C. Toro Blanch (Hospital Universitario Josep Trueta, Gerona); M.D. Malla Canet, M. Olmo Martínez (Hospital Santa Caterina, Parc hospitalari Martí i Julià. Salt, Gerona); J.M. Martínez Macías, J. Amores Vilà (Hospital de Palamós, Gerona); A. Morales Portillo, B. Martínez Castro (Hospital Universitario Arnau de Vilanova, Lérida); S. Conde Giner, I. Fonoll Tassier (Hospital Universitari Joan XXIII, Tarragona).

Galicia: M.I. Martín Herranz, S. González Piñeiro (Complejo Hospitalario Universitario de A Coruña); M. I. Pedreira Vázquez, A. M. Montero Hernández (Hospital Arquitecto Marcide, Ferrol, A Coruña); P. Sempere Serrano, P. Mayán Conesa (Complejo Hospitalario Universitario de Santiago de Compostela, A Coruña); R. Iglesias Barreira, C.A. Sandoval Aquino (Hospital Quirón Salud, Lugo); M. Samartín Ucha, A. Pichel Loureiro (Complejo Hospitalario Universitario de Vigo, Pontevedra); N. Ramos González (Hospital do Salnés, Villagarcía de Arosa, Pontevedra).

Madrid: C. Ortega Navarro, M. Vázquez Hernández (Hospital General Universitario Gregorio Marañón, Madrid); Á. García Martín, R. Torres Santos-Olmos (Hospital Universitario La Paz, Madrid); M. Muñoz García, M.J. Zamorano Serrano (Hospital Universitario Ramón y Cajal, Madrid); J.M. Caro Teller, L. Castro Arias (Hospital Universitario 12 de Octubre, Madrid); A. Delgado Latorre, N. López Laguna (Hospital Clínica Universidad de Navarra, Madrid); V. Gómez Tello (Hospital HLA Universitario Moncloa, Madrid); C. Ortega Navarro, S. Cruz Pardos (Hospital Virgen del Mar, Madrid); A. Carrero Fernández, R. Santoloya Perrín (Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid); J.J. Martínez Simón, S. Alonso Rodrigo (Hospital Universitario Fundación Alcorcón, Madrid); Y. Castellanos Clemente, C. Puivecino Moreno (Hospital Universitario de Fuenlabrada, Madrid); M. Hijazi Vega, M.V. Olalla Martin (Hospital Universitario de Getafe, Madrid); E. Díaz Gómez, M.J. Hernández Martínez (Hospital Universitario Severo Ochoa, Leganés, Madrid).

Murcia: C. Caballero Requejo, E. Cánovas (Hospital General Universitario Reina Sofía, Murcia); C. García Motos (Hospital Universitario Morales Meseguer, Murcia); A. Lázaro Cebas, A. Conesa Hernández (Hospital Universitario Santa Lucía, Cartagena, Murcia).

Basque Country: C. Ariz Arnedo, I. Iribar Dieguez (Hospital Bidasoa, Hondarribia, Guipúzcoa); L. Arteche Eguizabal, F. Melgosa Latorre (Hospital Alto Deba, Mondragón. Guipúzcoa); M.I. Fernández González, A.B. Maillo Arana (Hospital de Zumárraga, Guipúzcoa); A. Campino Villegas, M. de Miguel Cascón (Hospital Universitario de Cruces, Baracaldo, Vizcaya); M. Alonso Díez, M. Santisteban Bocos (Hospital Universitario de Basurto, Bilbao, Vizcaya); A. de Juan Arroyo, R. García Díez (Hospital de Urduliz, Vizcaya).

Valencia: C. Matoses Chirivella, J.A. Gutiérrez Navarro (Hospital General Universitario de Elche, Alicante); M. Sáez Bello, D. Castelló García (Hospital Universitaro Dr. Peset, Valencia); A. Rochina Astorga, P. Sánchez Llopez (Hospital de Manises, Valencia).

Andorra: A. Agulló Fenoll, I. Ruiz Vidal (Hospital Nostra Senyora de Meritxell, Andorra).

All authors accept responsibility as defined by the International Committee of Medical Journal Editors.

In the event of publication, all the authors cede exclusive rights of reproduction, distribution, translation, and public communication (by any means or sound, audiovisual, or electronic support) of this work to Farmacia Hospitalaria and, by extension, to the SEFH.

María José Otero: Writing – review & editing, Writing – original draft, Validation, Supervision, Methodology, Formal analysis, Data curation, Conceptualization. Montserrat Alonso Díez: Writing – review & editing, Writing – original draft, Methodology, Investigation, Conceptualization. Helena Esteban Cartelle: Writing – review & editing, Methodology, Investigation. Sonia Jiménez Hernández: Writing – review & editing, Investigation. Iria Miguéns Blanco: Writing – review & editing, Investigation. Marisol Samartín Ucha: Writing – review & editing, Investigation. Rosario Santolaya Perrín: Writing – review & editing, Investigation. Jesús Ruiz Ramos: Writing – review & editing, Writing – original draft, Methodology, Investigation, Conceptualization.