Abstract
Background Medication errors (MEs) are common in health care settings and pose a threat for the hospitalized population. Therefore, aspects of MEs were explored in a tertiary setting serving a diverse population. Objective To examine the occurrence, severity and reporting of MEs in hospitalized patients. Methods This retrospective analysis included 10,683 ME report forms that were received by the Medication Safety Unit of King Saud Medical City (KSMC) in 2015. ME outcomes were determined according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for categorizing MEs algorithm. Results A total of 13,677 MEs in 912,500 prescriptions were reported. The incidence rate of MEs was 1.5% (13,677/912,500). The highest percentage (42.2%) of MEs occurred during the transcription stage, and 70.0% of MEs were reported as near misses. Wrong frequency and wrong concentration accounted for nearly half of the MEs. Conclusion We found 1.5 MEs per 100 prescriptions; more than two-thirds of the MEs were preventable and were intercepted before reaching the patients. Most MEs reported by pharmacists occurred at the transcription stage while wrong frequency was the most common error type encountered. Further studies should explore the clinical consequences of MEs at a healthcare institution.
References
National Coordinating Council for Medication Error Reporting and Prevention. http://www.nccmerp.org/. Accessed 2 May 2017.
Patel N, Desai M, Shah S, Patel P, Gandhi A. A study of medication errors in a tertiary care hospital. Perspect Clin Res. 2016;7:168–73.
Bates DW, Boyle DL, Vliet MBV, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10:199–205.
Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care. 2005;17:15–22.
Aljadhey H, Mahmoud MA, Ahmed Y, Sultana R, Zouein S, Alshanawani S, et al. Incidence of adverse drug events in public and private hospitals in Riyadh, Saudi Arabia: the (ADESA) prospective cohort study. BMJ Open. 2016;6:e010831.
Alsulami Z, Conroy S, Choonara I. Medication errors in the Middle East Countries: a systematic review of the literature. Eur J Clin Pharmacol. 2013;69:995–1008.
Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care. 2002;11:340–4.
Ohta Y, Miki I, Kimura T, Abe M, Sakuma M, Koike K, et al. Epidemiology of adverse events and medical errors in the care of cardiology patients. J Patient Saf. 2016. doi:10.1097/PTS.0000000000000291.
Fertleman M, Barnett N, Patel T. Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds. Qual Saf Health Care. 2005;14:207–11.
Grissinger M. Pumping up the volume: tips for increasing error reporting. Pharm Ther. 2010;35:11–23.
Alshaikh M, Mayet A, Aljadhey H. Medication error reporting in a university teaching hospital in Saudi Arabia. J Patient Saf. 2013;9:145–9.
Khowaja K, Nizar R, Merchant RJ, Dias J, Bustamante-Gavino I, Malik A. A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan. Ther Clin Risk Manag. 2008;4:673–9.
Alassaad A, Gillespie U, Bertilsson M, Melhus H, Hammarlund-Udenaes M. Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observational and interventional study. J Eval Clin Pract. 2013;19:185–91.
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Ali, S., Aboheimed, N.I., Al-Zaagi, I.A. et al. Analysis of medication errors at a large tertiary care hospital in Saudi Arabia: a retrospective analysis. Int J Clin Pharm 39, 1004–1007 (2017). https://doi.org/10.1007/s11096-017-0514-7
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DOI: https://doi.org/10.1007/s11096-017-0514-7