(313) An Active Surveillance of Medication Error Monitoring Programme in a Tertiary Care Teaching Hospital: A Clinical Pharmacist Approach

Publication Number: 987

Background: Medication errors (ME) can have serious consequences, including patient harm as well as unnecessary hospital admissions and prolonged hospital stays, both of which reduce patient satisfaction and have an impact on their health conditions.

Objectives: To assess clinical pharmacists' initiatives in active medication error surveillance and to identify the contributing factors responsible for the reported medication errors.

Methods: A six-month prospective interventional study was carried out in a tertiary care hospital in south India. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) algorithm was used to classify the reported MEs. A data collection form developed by the researchers was used, and all ME occurring at any level in the departments of general medicine and surgery were included. Thus, the gathered data were categorically analyzed.

Results: A total of 245 medication errors were reported from the selected departments during the study period, and the incidence of medication errors was found to be 1.1%. There were 92 (43.39%) males and 120 (56.6%) females, amongst the 212 study participants identified. The majority of these errors occurred during the prescribing stage [180 (73.46%)], followed by documentation [55 (22.44%)] and administration [10 (4.08%)]. Incomplete prescriptions [159 (87.84%)] were the most commonly reported prescribing errors. Medication errors reported were classified according to the NCC MERP classification and the majority of the reported medication errors belonged to Category B [91(37.29%)] followed by Category C [86 (35.10%)]. A total of 648 contributing factors were identified for the 245 medication errors reported, of which the most common factor that contributed to the medication errors was workload [218 (33.64%)] and the least being communications [4 (0.61%)]. The other factors identified were communications, illegible prescriptions, patient transfer, peak hours, emergency situations, carelessness, distractions, duty shift, lack of attention, and stress.

Conclusions: Voluntary reporting of medication errors is essential for improving medication safety and the overall medication process within organizations. Thus, there is a need for technological innovation and other strategies to rectify any ME that exists in a hospital setting, hence improving patient safety.