A study of medication errors in a tertiary care hospital

Characteristics of the clinical pharmacist interventions at the National Center for Cancer Care and Research Hospital in Qatar

INTRODUCTION

Drug-related problems (DRPs) affect the health outcomes of patients during hospitalization. We sought to analyze the clinical pharmacist-documented interventions among hospitalized patients in the cancer hospital in Qatar.

METHODS

A retrospective analysis of electronically reported clinical pharmacist interventions of patients admitted to cancer units at Hamad Medical Corporation, Qatar was conducted. Extracted data was based on an overall 3-month follow-up period; March 1-31, 2018, July 15-August 15, 2018 and January 1-31, 2019. Categorical variables were expressed as frequencies and percentages, while continuous variables were expressed as mean ± standard deviation (SD).

RESULTS

A total of 281 cancer patients with 1354 interventions were included. The average age of the study participants was 47 years (SD ± 17.36). The majority of the study population was females (n = 154, 54.80%). The prevailing pharmacist intervention was the addition of a drug therapy (n = 305, 22.53%), followed by medication discontinuation (n = 288, 21.27%) and the addition of a prophylactic agent (n = 174, 12.85%). This pattern was similar across all subgroups (i.e., gender, age, ward), except for the urgent care unit, where an increase in medication dose was the third highest frequently identified intervention (n = 3, 0.22%). The two medication groups associated with the majority of interventions were the anti-infective and fluid/electrolyte agents. Most of the interventions documented were in the oncology ward (73.19%), while the urgent care unit had the least documented interventions (1.62%).

CONCLUSIONS

Our analysis showed that clinical pharmacists can effectively identify and prevent DRPs among hospitalized cancer patients.

A Quality Improvement Initiative to Reduce Prescription Error in a Pediatrics Outpatient Department at a Secondary-Level Community Hospital

Background Medication errors are common, especially by new trainees in primary care settings. Our study aimed at reducing the rate of prescription error in the pediatric outpatient department (OPD) of a secondary healthcare center in suburban north India using a quality improvement methodology. Methods Based on a survey and focused group discussion (FGD) involving all stakeholders, the identified problems and difficulties faced during outpatient prescriptions, interventions, and outcome parameters were drafted. The primary outcome measure was the prescription error rate evaluated by a senior resident (SR) of pediatrics, and the secondary outcome measures included the frequency of antibiotic prescriptions and investigations. Intervention Two cycles of Plan-Do-Study-Act (PDSA) were conducted on accessible drug formularies and standard treatment protocols for common pediatric conditions. Results The mean baseline prescription error was 72.2% (95% confidence interval (CI): 63.2-81.1). After the implementation of the first PDSA cycle, the mean error rate was 46.5% (95% CI: 36.6-56.5). There were eight consecutive points of prescription error below the control limit (63.2% and 81.1%) of the baseline. The PDSA-2 cycle showed the same shift to below the control limit (36.6% and 56.5%). The mean error rate found at the end of the PDSA-2 cycle was 22.5% (95% CI 15.7-29.5). There was no clinically significant difference in the number of investigations or antibiotics prescribed. Conclusion The application of standardized drug formularies and standard treatment protocols (STPs) can help reduce prescription errors, especially in a primary care setting. Expansion of such techniques to other centers could be particularly useful.

Characteristics of the clinical pharmacists' interventions at the main general tertiary care hospital in Qatar

Medication-related problems (MRPs) are prevalent throughout healthcare systems, whereby pharmacy-based interventions are pivotal to reducing occurrence. In the Middle East, including Qatar, the professional roles of pharmacists have been expanding to improve patient safety. This study aimed to characterize and analyze pharmacist-led interventions among hospitalized patients in the leading general hospital in Qatar. A retrospective analysis of pharmacist interventions in the internal medicine ward, critical care unit, and emergency department (ED) was conducted. Data were extracted from three periods of 1 month (March 1-31, 2018, July 15-August 15, 2018, and January 1-31, 2019). A descriptive type of analysis was undertaken. A total of 340 patients with 858 interventions were analyzed. The average age of the study participants was 51 years (SD ± 17.7). The study population was predominantly male (65%). The prevailing pharmacist intervention was adding drug therapy (27%), followed by medication discontinuation (18%) and dosage adjustments (16%). This pattern was maintained across all subpopulations, e.g., gender, age, and ward, except for the ED, where cessation of medication was the most frequent intervention (4%). The two pharmacological classes associated with most interventions were anti-infective and cardiovascular agents. Pharmacist interventions effectively identify, prevent, and resolve MRPs in general inpatient settings in Qatar.

The Extent of Medication Errors During Hajj in the Kingdom of Saudi Arabia

Background Medication errors are frequently identified in healthcare institutions and pose a risk to patients. The mass gathering during Hajj may expose the pilgrims to numerous health risks. No study has reported the extent of medication errors during Hajj in Saudi Arabia. We investigated the rate, nature, reporting, severity, and causes of medication errors in Hajj pilgrims. Methodology A retrospective analysis of medication errors reported by healthcare professionals was conducted from July 5, 2022, to July 15, 2022, at Mina Al Wadi Hospital, Saudi Arabia. This study included all medication error report forms collected during the Hajj season. The National Coordinating Council for Medication Error Reporting and Prevention Index was used to classify the severity of medication errors. Results There were reports of 43 medication errors in 3,210 prescriptions. The medication error incidence rate was 1.5% (43/3,210). The highest proportion of medication errors (83.72%, 95% confidence interval (CI) = 72.69-94.75) occurred during the prescribing phase, and 97% (95% CI = 93.16-100.0) of medication errors were classified as near misses. Wrong drugs (23.25%) and frequency (18.60%) were responsible for nearly half of the medication errors. Lack of drug information was the leading cause of reported medication errors (58.14%), followed by environmental, personnel, and workload issues (23.25%), and look-alike/sound-alike medication issues (18.60%). Conclusions This study found that the incidence of medication errors was consistent with the global standard, and many of them did not reach pilgrims and were preventable. This highlights the importance of targeted interventions. Incorrect medication was the common type of medication error, highlighting a crucial area for intervention and improvement. Lack of drug information was the primary underlying factor in the occurrence of medication errors. Pharmacists were more likely than other healthcare professionals to report medication errors, highlighting the importance of their involvement in improving medication safety among pilgrims. Future research needs to focus on examining the effectiveness of interventions (e.g., provision of education regarding medicines and medication review) in reducing medicine-related events during Hajj.

Impact of clinical pharmacist interventions on economic outcomes in a cardiology setting in Qatar

We sought to investigate the economic impact of preventing adverse events in a cardiology setting in Qatar as an effect of the clinical pharmacist as an intervention. This is a retrospective study of interventions by clinical pharmacists within an adult cardiology setting in a public healthcare setting (i.e Hamad Medical Corporation). The study included interventions that took place in March 2018, July 15, 2018-August 15, 2018, and January 2019. The economic impact was measured via calculating the total benefit, defined as the sum of the cost savings and the cost avoidance. Sensitivity analyses were adopted to confirm the robustness of the results. The pharmacist intervened in 262 patients, resulting in 845 interventions, with appropriate therapy (58.6%) and dosing/administration (30.2%) being the most frequent categories of reported interventions. Cost savings and cost avoidance resulted in QAR-11,536 (USD-3,169) and QAR1,607,484 (USD 441,616), respectively, yielding a total benefit of QAR1,595,948 (USD438,447) per three months and QAR6,383,792 (USD1,753,789) per a year.

Current Situation of Medication Errors in Saudi Arabia: A Nationwide Observational Study

OBJECTIVES

Medication errors are common and highly preventable events that significantly affect patients' health. This nationwide study primarily aims to quantify the rate and level of harm from the reported medication errors and to determine the medication process stages in which the reported errors occurred.

METHODS

This retrospective observational study concerns medication errors reported to the General Department of Pharmaceutical Care database from March 2018 to June 2019. The database stores all aspects of medication error information, including patient, medication, and error information, along with the job position of the staff involved and contributing factors. The medication use process was categorized into these stages: ordering/prescribing, transcribing, dispensing, administering, and monitoring. We recorded each medication error based on categories from the U.S. National Coordinating Council for Medication Error Reporting and Prevention.

RESULTS

A total of 71,332 medication error events were reported to the database. Physicians made 63,120 (88.5%) reported errors, and pharmacists most frequently detected the errors (75.9%). The majority of reported errors appeared at the prescribing phase (84.8%), followed by the transcribing (5.8%) and dispensing (5.7%) phases. A total of 4182 (5.8%) errors reached the patient. Health care professionals' work overload and lack of experience were associated with 31.6% and 22.7% of the reported errors, respectively.

CONCLUSIONS

Our study highlights the concern regarding medication errors and their low reporting by indicating that pharmacists reported and detected the majority of errors. Promoting a no-blame culture and education for health professionals is vital for improving the error-reporting rate.

Evaluation of Medication Errors in a Tertiary Care Hospital of a Low- to Middle-Income Country

Introduction Medication errors (MEs) are a major public health concern as they are detrimental to patient safety, compromise patients' confidence in the healthcare system, increase healthcare costs, and adversely affect the patient's quality of life. This is especially true in low to middle-income countries where the significance of MEs is largely undervalued. This study aims to investigate the prevalence of MEs and analyze the causes, medicines involved, reporting, and severity of MEs in a tertiary care setting. Methods A prospective observational study was conducted from March 2020 to February 2021 in a tertiary care teaching hospital in South India. The data was collected after reviewing patient medical records, by interviewing patients and healthcare professionals. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was used to evaluate MEs. Results A total of 557 MEs were identified from 3798 patients with a prevalence of 14.6%. Prescribing errors were the most commonly observed ME followed by errors related to documentation of medical records, administration-related errors, and dispensing errors. Lack of time for documentation of medication records, shift change and work overload were common causes of MEs. The majority of MEs were category A and B of the NCC MERP severity index. Conclusion Antibiotics and proton pump inhibitors were the most common medicines involved in MEs. Prescribing and documentation errors were most prevalent. Implementation of systems like strict adherence to treatment guidelines, computerized provider order entry (CPOE), barcode medication administration, and closed-loop electronic medication management systems may greatly help reduce MEs. All healthcare institutions should undertake routine audits to determine the prevalence and causes of medication errors.

Analysis of stress ulcer prophylaxis drug regimentation in surgical patients

OBJECTIVES

The World Health Organization (WHO) estimated that more than 50% of drugs were prescribed incorrectly, including stress ulcer prophylaxis (SUP) drugs. Prescribing SUP drugs in incorrect doses and frequencies are considered irrational, and may affects to the effectivity of the therapy. This research aimed to assess the appropriateness of the SUP drugs regimentation in the inpatient surgery room at Dr. Soetomo Hospital, Surabaya, Indonesia.

METHODS

This research was cross-sectional study and conducted for 4 weeks in 2019 in the inpatient surgery room of Dr. Soetomo Hospital. The population was SUP drugs that were prescribed in inpatient surgery room. Those SUP drugs with indications for the prevention of stress-induced ulcers that complied to the terms listed on the American Society of Health-System Pharmacists (ASHP) were included as the samples, and vice versa. The samples then assessed for their regimentation appropriateness using the dose and frequency standard of ASHP.

RESULTS

There were 224 dose units taken as sample, from the total population of 1,404 SUP drugs. The result showed that as much as 48.2% of SUP medications were given to the patients in inappropriate regimentation. Of that number, all ranitidine injection were inappropriately regimented. On the contrary all omeprazole injection dose units were appropriately regimented, meanwhile the amount of appropriate regimentation of sucralfate suspension were 74.6%.

CONCLUSIONS

According to ASHP standard, the SUP drugs in the inpatient surgery room at Dr. Soetomo Hospital were mostly given in inappropriate regimentation. Further research is needed to explore how will those inappropriate regimentation affect on the efficacy of therapy in the patients.

Description of pharmacists' reported interventions to prevent prescribing errors among in hospital inpatients: a cross sectional retrospective study

Background

Prescribing errors (PEs) are a common cause of morbidity and mortality, both in community practice and in hospitals. Pharmacists have an essential role in minimizing and preventing PEs, thus, there is a need to document the nature of pharmacists’ interventions to prevent PEs. The purpose of this study was to describe reported interventions conducted by pharmacists to prevent or minimize PEs in a tertiary care hospital.

Methods

A retrospective analysis of the electronic medical records data was conducted to identify pharmacists’ interventions related to reported PEs. The PE-related data was extracted for a period of six-month (April to September 2017) and comprised of patient demographics, medication-related information, and the different interventions conducted by the pharmacists. The study was carried in a tertiary care hospital in Riyadh region. The study was ethically reviewed and approved by the hospital IRB committee. Descriptive analyses were appropriately conducted using the IBM SPSS Statistics.

Results

A total of 2,564 pharmacists’ interventions related to PEs were recorded. These interventions were reported in 1,565 patients. Wrong dose (54.3 %) and unauthorized prescription (21.9 %) were the most commonly encountered PEs. Anti-infectives for systemic use (49.2 %) and alimentary tract and metabolism medications (18.2 %) were the most common classes involved with PEs. The most commonly reported pharmacists’ interventions were dose adjustments (44.0 %), restricted medication approvals (21.9 %), and therapeutic duplications (11 %).

Conclusions

In this study, PEs occurred commonly and pharmacists’ interventions were critical in preventing possible medication related harm to patients. Care coordination and prioritizing patient safety through quality improvement initiatives at all levels of the health care system can play a key role in this quality improvement drive. Future studies should evaluate the impact of pharmacists’ interventions on patient outcomes.

Prescribing errors among adult patients in a large tertiary care system in Saudi Arabia

BACKGROUND

Multiple studies have investigated medication errors in hospitals in Saudi Arabia; however, prevalence data on prescribing errors and associated factors remains uncertain.

OBJECTIVE

Assess the prevalence, type, severity, and factors associated with prescribing errors.

DESIGN

Retrospective database review.

SETTING

Large tertiary care setting in Riyadh.

PATIENTS AND METHODS

We described and analyzed data related to prescribing errors in adults (>14 years of age) from the Medication Error Electronic Report Forms database for the two-year period from January 2017 to December 2018.

MAIN OUTCOME MEASURE

The prevalence of prescribing errors and associated factors among adult patients.

SAMPLE SIZE

315 166 prescriptions screened.

RESULTS

Of the total number of inpatient and outpatient prescriptions screened, 4934 prescribing errors were identified for a prevalence of 1.56%. The most prevalent types of prescribing errors were improper dose (n=1516; 30.7%) and frequency (n=987; 20.0%). Two-thirds of prescribing errors did not cause any harm to patients. Most prescribing errors were made by medical residents (n=2577; 52%) followed by specialists (n=1629; 33%). Prescribing errors were associated with a lack of documenting clinical information (adjusted odds ratio: 14.1; 95% CI 7.7-16.8, P<.001) and prescribing anti-infective medications (adjusted odds ratio 2.9; 95% CI 1.3-5.7, P<.01).

CONCLUSION

Inadequate documentation in electronic health records and prescribing of anti-infective medications were the most common factors for predicting prescribing errors. Future studies should focus on testing innovative measures to control these factors and their impact on minimizing prescribing errors.

LIMITATIONS

Polypharmacy was not considered; the data are from a single healthcare system.

CONFLICT OF INTEREST

None.

Testing of Defects per Million Medication Orders as a SMART Indicator for Monitoring Medication Safety in Admission and Discharge Orders

Introduction

The study investigated the use of defects per million medication orders (DPMMO) as a SMART (specific, measurable, achievable, realistic, and timely) indicator for monitoring medication safety in admission and discharge orders. The study aimed to develop and test a new indicator as an investigator of medication safety.

Methods

The study was conducted in 2018 at King Saud Medical City in Riyadh City in Saudi Arabia. A retrospective cross-sectional design was used. The research sample had 292 patients. The selected medication orders included two types of medication orders (admission and discharge order). After sufficient data had been gathered from the hospitals, a statistical analysis was carried out.

Results

Analysis of admission and discharge orders indicated that defects per million opportunities (DPMO) and DPMMO count were slightly low, while the sigma level for admission orders was slightly high. Thus, the admission order process was slightly better than the discharge order process.

Conclusion

The DPMMO indicator could serve as a SMART indicator of medical safety. It can be used as a standardized indicator in any healthcare facility, which serves as a recommendation guide in monitoring and evaluating healthcare processes or systems that affect the safety and outcomes of patients.

The Magnitude of Medication Administration Errors among Nurses in Ethiopia: a Systematic Review and Meta-analysis

Introduction: Nurses are the final safety check in the process of medication administration process to prevent errors that adversely affect life; yet death of comprehensive evidences in Ethiopia. The present study aimed to assess the pooled magnitude of MAEs (Medication Administration Errors) in Ethiopia. Methods: Systematic literature search in the databases of Pub-Med, Cochrane, and Google Scholar for gray literature were performed until December 3, 2018. The quality of study was assessed using criteria adopted from similar studies. Heterogeneity test and evidence of publication bias were assessed. Moreover, sensitivity analysis was also performed. Pooled prevalence of MAE was calculated using the random effects model. Results: A total of 2142 medication administrations were from observational and 681from self-reported studies were included in this systematic review and meta-analysis. The most prevalent and frequently reported type of MAEs was documentation error (52% to 87.5%) and time error (25.5% to 58.5%) respectively. Overall, the pooled magnitude of MAE was found to be 39.3% (95% CI, 29.1%-49.5%).It has no evidence of significant heterogeneity (I2 = 0%, P = 0.57) and publication bias Egger's test (P = 0.40). Conclusion: Overall, more than one in four observed/perceived medication administrations had errors. Documentation error is the most prevalent type of error. Nurses are suggested to strengthen their focus on the rights of medication administration guide particularly, documentation of their activities need special attention.

Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand?

Background

Medication error in developed countries is of primary concern when there is a question of adversity to a patient's health, but in developing countries like India, it is just a term and its significance is undervalued. The incidence of medication error is essential to estimate the proper medical care provided in the healthcare system.

Objective

The main objective of the study is to determine the incidences of medication error in critical care unit and to evaluate its risk outcomes.

Materials and methods

This is a prospective observational study conducted over a period of 6 months in a critical care unit of a tertiary care hospital. Medication chart review method was opted for data collection. The medication errors were mainly classified as prescription, transcription, indenting, dispensing, and administration error. A total of 6,705 charts were reviewed. The NCCMERP risk index was used to evaluate the outcome of errors.

Results

Of the total 6,705 charts, 410 medication errors were found, i.e., 6.11%. The most common error is transcription error that constitutes 44.1% of the total errors, followed by prescription error 40%, and administration error 14%. The frequency of indenting and dispensing errors is negligible with 1.5% and 0.5%, respectively. The main causes of medication errors are due to incomplete prescription 50.2% and wrong doses 22.9%. In drug class, antibiotics and antihypertensive agents are most prone to medication error. About 87.1% errors belonged to the Category B of National Coordinating Council for Medication Error Reporting and Prevention risk index.

Conclusion

Majority of the errors are transcription errors followed by prescription and administration errors. Consultant doctors have to be more vigilant during prescribing and verifying the medication charts. Clinical pharmacists should act as a checkpoint at each step of medication process to identify and prevent medication errors.

How to cite this article

Zirpe KG, Seta B, Gholap S, Aurangabadi K, Gurav SK, Deshmukh AM, et al. Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand? Indian J Crit Care Med 2020;24(9):799–803.

Framework for Patient Safety

A commitment on quality objectives is a crucial element of quality policy in HROs, such as hospitals and other healthcare institutions. The quality of care includes objectives related to effectiveness, efficiency, and a patient's experience. Healthcare organizations are also aware of the importance of promoting safety practices and the resiliency analysis of the clinical practice in order to improve quality. Patient Safety Culture has been defined as the product of individual and group values, attitudes, competencies, and patterns of behavior that determines their commitment, style, and proficiency with the organization's health and safety programs. The safety culture of a health center offers an indirect means for its involvement in quality. Poor involvement of professionals in safety has negative consequences for patients. Envisioning the future of patient safety is more than an academic exercise. Appealing visions can help channel human energies, set new directions, and open the doors to alternative approaches. An outside observer is struck by three characteristics that are very different from the culture of the early 21st century: a deep sense of individual and institutional accountability for safety, an emphasis on fairness and transparency, and pervasive collaboration and teamwork based on mutual respect. Speaking up is important for patient safety, but healthcare professionals often hesitate to voice their concerns. Direct supervisors have an important role in influencing speaking up. However, good insight into the relationship between managers' behavior and employees' perceptions about whether speaking up is safe and worthwhile is still lacking. The evaluation should cover the following areas in both instruments: strategy (inquiry on their commitment to the quality and safety strategy, indicators' feedback, and risks maps), support systems for clinical decisions (digital record algorithms to make decisions and for accessibility to patient clinical information), equipment (adequacy), follow-up (availability of tests when needed), person-centered care (respect of patients' values and preferences), evidence-based practice (practices in accordance with guidelines), delays (on scheduled tests, surgery, and outpatient care), and cost-effective treatments (adequacy).

Assessment of prescription pattern and prescription error in outpatient Department at Tertiary Care District Hospital, Central Nepal

Background

The rational use of medicine improves patient’s quality of life. Excessive and inappropriate prescriptions result in severe consequences. The study of drug use patterns and prescription errors is necessary to promote rational drug use in developing countries. The aim of the study was to evaluate prescription practice and help to the quality use of medicine.

Methods

A retrospective, cross-sectional and quantitative study was conducted at Bharatpur District Hospital in central Nepal. The outpatient prescriptions retained at the pharmacy from November to December 2017 were used to evaluate prescription patterns and errors. The total of 770 prescriptions were reviewed. The stratified random sampling method was used.

Result

The total of 2448 drugs were prescribed in 770 prescriptions or patients. The average number of drugs per encounter was 3.2. The percentage of encounter with antibiotic and injection was 37.9% (n = 292) and 0.7% (n = 5), respectively. The percentage of drugs prescribed by generic and from an essential medicine list of Nepal was 2.9% (n = 72) and 21.3% (n = 521), respectively. The most common 32.5% of prescriptions contain three drugs and 24.7% of prescriptions contain four drugs. The average prescription errors per prescription were 3.4. Among total errors, omission errors related to prescriber were 1.5 (n = 1135), omission errors related to the drug were 1.5 (n = 1189) and commission errors were 0.3 (n = 269). The total of 249 drug interactions were found in 19.1% (n = 147) prescriptions. The common prescription errors were due to failure to mention prescriber name 87.5% (n = 674), failure to mention prescriber signature 19.2% (n = 148) and failure to mention diagnosis 39.2% (n = 302).

Conclusion

The study shows low compliance with WHO prescribing indicators and high prescription errors. The prescribing practices were not confirmed to the standard recommended by WHO. Prescribing from the Essential Drug List (EDL), low rates of generic prescribing, high antibiotic prescribing and polypharmacy were a major problem. The study found major errors in prescriber and prescribed medicine details. Remarkable drug interactions were seen in prescribed medicines. The study recommended necessary practices and policy formulation and implementation by DTC and regulatory bodies to promote the rational use of medicine.

An analysis of adverse drug reactions in extremes of age group at tertiary care teaching hospital

Objectives:

To analyze clinical spectrum, seriousness, outcome, causality, severity and preventability of ADRs in geriatrics and pediatric patients.

Materials and Methods:

All ADRs reported in geriatrics (≥ 65 years) and pediatrics (≤ 12 years) indoor as well outdoor patients from January, 2010 to April, 2016 at ADR monitoring centre, Department of Pharmacology, B. J. Medical College and Civil Hospital were identified. A retrospective analysis was carried out for clinical presentation, causality (as per WHO-UMC scale and Naranjo's algorithm), severity (Hatwig and Seigel scale) and preventability (Schaumock and Thornton criteria).

Results:

Out of 3690 ADRs, 160 were in geriatric patients (4.33%) while 231 in pediatric patients (6.26%). The most commonly affected body system was gastrointestinal (53, 33.13%) followed by neurological disorders (26, 16.25%) in geriatric patients. While in pediatric patients, the most commonly affected body system was skin and appendages (73, 31.60 %) followed by gastrointestinal disorders (58, 25.11%). The most common causal drugs in geriatric patients was cardiovascular (38, 23.75%) followed by antimicrobials (28, 13.25%). While in pediatric patients, the most common causal drug group was antimicrobials (85, 33.46%) followed by blood products (36, 14.12%). Total 17 ADRs reported following vaccination, 7 (41.17%) were injection site abscess and 11 (64.70%) were due to pentavalent vaccine. Polypharmacy was common in geriatrics (31, 19.37%). Causality assessment for majority of ADRs in geriatrics (83, 52.5%) and pediatrics (171, 67.32%) were probable.

Conclusion:

ADRs are common in geriatric and pediatric patients usually within four weeks of oral therapy. Active surveillance of drug safety monitoring in these vulnerable population is recommended.

Analysis of medication errors at a large tertiary care hospital in Saudi Arabia: a retrospective analysis

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.