Learning from error: identification and analysis of causative factors leading to medication error in an inpatient hospital setting

Subodh Kumar, Anju Madhwar, Anuj Kumar Pathak, Dibyajyoti Saikia


Background: Medication errors are preventable causes of medical error. These errors may happen at various steps of medication process. This study tries to find common errors during four stages i.e. prescribing, transcribing, dispensing and administration.

Methods: It was a cross sectional study in a tertiary care teaching hospital in north India. Five hundred patients were randomly selected for the study. Medication error was checked at different level by a medication audit tool. Direct observation, chart reviews and personal communication with patients, nurses and pharmacist were done to complete the details of tool. Root cause analysis was done after discussing with concerned professionals. Severity of the medication errors were assessed using national coordinating council for medication error reporting and prevention (NCCMERP) proposed medication error index.

Results: Medication error rate was found to be around 50%. i.e. every one of two patients received some form of error. Prescribing error were most common cause of error followed by administration error and transcription error. Dispensing error was least common. Root cause analysis indicated casual attitude, inadequate knowledge and training as the main causes.

Conclusions: This study was an initial step in recognising error prone areas of medication management. It can be used to develop standard procedures and formulating guidelines for prevention of such errors.


Medication error, Prescribing error, Administration error,Transcription error, Dispensing error

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