Objective: To identify the incidence of medication error in a tertiary care hospital and to document the role of drug information centre to prevent such errors.
Methods: The retrospective cross-sectional study was conducted at the Security Forces Hospital, Riyadh, Saudi Arabia, and comprised review of secondary data collected from the Drug Information Centre from March 2013 to February 2016. The errors were categorised as under-prescribing, dispensing, administrating and transcription, while the received inquiries were classified according to the inquirer; physicians, pharmacists and nurses. The score was given according to the Grade of Severity scale. Data was analysed using IBM SPSS Statistics for Windows, version 20. Armonk, NY: IBM Corp. Categorical variables were presented as frequency and percentage.
Results: Among the 2800 drug-related inquiries received, 238(8.5%) medication errors were detected. The inquirers of these queries included 108(45.4%) nurses. Administration errors were the highest 113(47.5%), while the least were transcription errors 31(13%). Majority of errors were committed by nurses 113(47.5%). Grade 2 errors were the most common 86(36.10%), while grade 4 life-threatening errors were minimal 2(0.8%). There were significant differences in the number of received questions based on the specialty (p˂0.05), staff having committed the error (p˂0.01) and the type of errors detected (p˂0.01).
Conclusion: The prevalence of medication errors committed by healthcare providers was high.
Keywords: Medication error, Drug information centre, Administration, Physician, Pharmacist. (JPMA 73: 755; 2023)
Medication errors are extremely prevalent, happening in any phase of the drug-use practices, including prescribing, dispensing, medication administration and monitoring.1 Medication errors represent a foremost cause of illness and death, yet they have persisted.2,3 Medication error is defined as any avoidable pharmacological incident that is detrimental to patient or may bring about improper use of medication.4,5 Potential error (near-miss) is defined as the error detected before reaching the patient.5 Different kinds of medication errors are recognised globally, including prescription errors, dispensing errors, transcribing errors, and administration errors.6 Prescription errors occur due to omissions or oversights, improper selection of drugs or doses, prescribing brand names, erroneous writing and illegible handwriting.7 Discrepancy or incongruity between prescription order or instruction and the medication delivered to the patient or ward is called dispensing error.8 Illegible handwriting, unit misinterpretation, abbreviation usage, and mistakes in reading may lead to transcription errors.9 The disparity between the originally-planned prescription order and what the patient receives or was supposed to be given is referred to as administration errors.10 Administration errors may include wrong dose, wrong timing, wrong patient or omission of doses.7
Medication errors can result in higher costs, protracted hospital stays or lethal harm.11 The schedule of antibiotic administration, drugs with higher risk and the variable methods used for drug administration are significant risk areas with regard to medication errors.12 Therefore, it is imperative to detect, classify and analyse medication errors and initiate proper steps to minimise them. Approximately 30% of damaging incidents during hospital stay are due to medication errors.13 Current evidence shows that adverse drug reaction (ADR)-associated morbidity occurs at a median rate of 20%.14 However, there is dearth of information in Saudi Arabia regarding the level and outcome of medication errors. A study in Riyadh reported that 18.7% of prescriptions were found to have medication errors which is an alarming and anomalous rate that must be emphasised and controlled.15
The Drug Information Service (DIS) offers objective, coherent, independent, accurate and evidence-based information, largely as a response from healthcare providers to existing patient-oriented problems.16 Drug information centres (DICs) in hospitals contribute significantly towards improving the safety of medications by avoiding potential medication errors in addition to developing management strategies to resolve actual medication errors.13 The detection of potential or actual medication errors aids the development of effective and safe practices that guarantee sufficient, reasonable and logical use of drugs, thus improving patient safety.13 Several current studies have explored, assessed and analysed medication errors.17-20 Likewise, a few studies in Saudi Arabia have emphasised the issue of medication errors.15,21,22
However, to the best of our knowledge, there has been no study conducted in Saudi Arabia to evaluate the role of DICs in detecting medication errors. The current study was planned fill the gap by describing the type of medication errors detected by DIC, and to unravel the sources of errors.
Materials and Methods
The retrospective, quantitative, analytical, cross-sectional study was conducted at the Security Forces Hospital (SFH), Riyadh, Saudi Arabia, which is a 600-bed tertiary care facility. The SFH DIC is run by two specialised pharmacists. DIS is accessible from 8 am to 5 pm during working days; from Sunday to Thursday. On-call service is also provided by the DIC after working hours and on weekends. After approval from the institutional ethics review committee, the current study used secondary data collected from the documented DIC answers reported from March 2013 to February 2016. The DIC used updated reference books and Micromedex and Lexicomp databases as resources to answer the users' questions and enquiries. The inquiries were received from the hospital staff either by telephone, e-mail, or in person. The received inquiries were classified according to the inquirer; physicians, pharmacists and nurses. The errors were categorised under prescribing, dispensing, administrating and transcription, using the Grade of Severity scale23 (New South Wales Health Department), according to which, 0=No error; 1=the incident is likely to have little or no effect on the patient;
2=the incident is likely to lead to an increase in minor errors level of care, like review, investigations, or referral to another clinician; 3=the incident is likely to lead to permanent reduction in bodily functioning leading to increased length of stay, surgical intervention, major errors; 4=the incident is likely to lead to a major permanent loss of function; and 5=the incident is likely to lead to death.
Data was analysed using IBM SPSS Statistics for Windows, version 20. Armonk, NY: IBM Corp. Categorical variables were presented as frequency and percentage.
Among the 2800 drug-related inquiries received, 238(8.5%) medication errors were detected. There was an increasing trend of medication errors over the duration of study; 61(25.6 %) in 2013, 75(31.5%) in 2014, and 102(42.9%) in 2015.
The inquirers of these queries included 108(45.4%) nurses. Administration errors were the highest 113(47.5%), while the least were transcription errors 31(13%). Majority of errors were committed by nurses 113(47.5%). Grade 2 errors were the most common 86(36.10%), while grade 4 life-threatening errors were minimal 2(0.8%) (Table).
There were significant differences in the number of received questions based on the specialty (p˂0.05), staff having committed the error (p˂0.01) and the type of errors detected (p˂0.01).
Medication errors are frequently unreported due to reasons associated with fear of being reprimanded by the authorities, feelings of culpability, and anxieties over severity of the error.24 In a study, only about 25% of the errors were reported by staff members.25
The current study detected four types of medication errors, which is consistent with earlier studies.5,26 The administration errors ranked the highest (47.5%), while the lowest were transcription errors (13%). These results contradict some international studies. Mathaiyan et al. demonstrated that prescription errors were the most frequently occurring error (54.8%), with only 20.7% administration errors. Lisby et al. also reported that ordering errors were the fourth highest (39%), whereas transcription errors were the second highest.27 These variations in findings can be attributed to differences in the level of education, qualifications and training of healthcare providers from one country to another.
Majority of questions in the current study were asked by the nursing staff (45.40%), followed by pharmacists (41.20%) with a significant difference among healthcare providers (p˂0.05), which may be due to the relatively higher number of nurses in the hospital compared to other categories of healthcare providers. Nurses were found to have committed most medication errors (47.5%) with a significant difference in comparison with other healthcare professionals (p˂0.01). These findings are in line with other studies indicating that nurses’ knowledge in pharmacology and drug management is insufficient.27 Language barrier and poor communication between staff, such as physicians and nurses, were also considered to be the reasons behind the highest number of errors being committed by nurses.26,28,29 Furthermore, the pharmacists committed a higher number of errors (34.5%) compared to physicians (18.1%) in the current study, which can be attributed to the low number of pharmacists in the hospital that leads to deficient performance due to work overload.
In terms of severity of medication errors, most errors in the current study were of grade 2 (36.10%), while grade 4 life-threatening errors were <1%. A study performed in north-western England found that 54.1% of errors were significant, 41.9% were minor errors, while life-threatening errors constituted <1%.30 In the current three-year study, the number of detected errors increased with every passing year. The expansion of services in the hospital, like increased number of clinics and recruitment of fresh staff not well familiar with practice settings as well as low concern for pharmacovigilance educational courses and training in the hospital might be the possible reasons for such proportional relationship.
The current study also underlined the significant role of DIC pharmacists in reducing medication errors.
Based on the findings, the study recommends encouraging medical staff to contact DIC to clarify any medication-related ambiguity. Educational sessions and training for healthcare professionals, especially nurses, will also be rewarding in terms of decreasing the number of medication errors. DICs should be established at all hospitals, and should be managed by well-trained and well-informed pharmacists having advanced resources at their disposal. Applying a computerised physician order entry (CPOE) system, and unit dose-dispensing cabinet (Pyxis machines) is also necessary. Having an electronic detecting system that may guard against missing any error will also be beneficial.
The current study has certain limitations, like under-detection of medication errors, incomplete question logs, unanalysed medication errors, and difficulties in tracking the electronic drug information in question log systems. Future studies should be mindful of these limitations.
The prevalence of medication errors committed by healthcare providers was high. The role of DICs was found to be vital in detecting medication errors.
Conflict of interest: None.
Source of Funding: None.
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