Medication errors reported in a tertiary care private hospital in Eastern India: a three years experience
DOI:
https://doi.org/10.18203/2319-2003.ijbcp20202186Keywords:
Medication error, Eastern India, Private hospital, Administration errors, Prescription errorAbstract
Background: Medication errors (MEs) can cause significant harm to patients. The MEs identified through reporting processes currently report only a fraction of the actual number of MEs. Data about MEs is limited in India, especially from eastern and north-eastern parts of India. The objective of this study was to analyse the various types of Medication errors reported in a tertiary care private hospital in Eastern India. The aim was to determine the various factors associated with these errors and steps to be taken to reduce the MEs in this healthcare setup.
Methods: We carried out a prospective passive surveillance study over the course of 3 years (2016-2018) on 50,822 admitted patients after obtaining approval from the Institutional Ethics Committee. A detailed root-cause analysis was performed for every reported error by a team of healthcare quality professionals and clinical pharmacists along with a clinical pharmacologist followed by appropriate preventive and corrective actions.
Results: In our study, a total number of 88 medication errors were reported from a sample size of 50,822 (0.0017%). 61 of the reported MEs were administration errors (69.3%). Higher preponderance of medication errors was seen in male patients (53.1%) in comparison to female patients (46.9%).
Conclusions: In this study gross under-reporting of MEs were observed which is in line with previously published studies in India. The reasons reported for gross under-reporting can function as an effective tool to ensure improved reporting of MEs and implementation of mitigation strategies.
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References
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(4):168-73.
Hepler CD, Strand LM, Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533-43.
Ministry of Health Malaysia. Guideline on medication error reporting. 1st ed. Malaysia: Ministry of Health Malaysia; 2009.
Davis NM, Cohen MR. Medication Errors: Causes and Prevention. Huntingdon Valley, PA: Neil M. Davis Associates; 1981.
The National Coordinating Council for Medication Error and Prevention (NCCMERP). The Council: Moving into the Second Decade ‘Developing Recommendations and Offering Tools’; 2010.
Hermon R, Williams PAH. A Study on Information Induced Medication Errors, SRI Security Research Institute, Edith Cowan University, Perth, Western Australia; 2013.
Kumar KS, Venkateswarlu K, Ramesh A. A study of medication administration errors in a tertiary care hospital. Indian J Pharm Pract. 2011;4:37-42.
Reddy P, Mandha M. Medication errors: identification, prevention and implementation of safe medication practice in a tertiary care teaching hospital. World J Pharm Sci. 2015;4:1249-56.
Sheikh D, Mateti UV, Kabekkodu S, Sanal T. Assessment of medication errors and adherence to WHO prescription writing guidelines in a tertiary care hospital. Future J Pharma Sci. 2017;3:60-4.
Rekha B, Saurabh B. Evaluation of prevalence of medication errors in a multispecialty teaching hospital, Dehradun. IJOPP. 2013;6:19-24.
Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Archives Disease Childhood. 2000;83(6):492-7.
Jeraisy AMI, Alanazi MQ, Abolfotouh MA. Medication prescribing errors in a pediatric inpatient tertiary care setting in Saudi Arabia. BMC Res Notes. 2011;4(1):294.
National Coordinating Council for Medication Error and Reporting and Prevention. Available at: http://www.nccmerp.org/aboutMedErrors.html. Accessed on 13th May 2019.
Wolf ZR, Hughes RG. Error Reporting and Disclosure. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 35. Available at: http://www.ncbi.nlm.nih.gov/ books/NBK2652. Accessed on 3 January 2020.
Balas MC, Scott LD, Rogers AE. frequency and type of errors and near errors reported by critical care nurses. Can J Nurs Res. 2006;38(2):24-41.
Banja JD. Problematic medical errors and their implications for disclosure. HEC Forum. 2008;20(3):201-13.
Jolayi S, Hajibabaei F, Peyrovi H, Haghani H. Review and report the occurrence of errors and their association with the working conditions of nurses working in hospitals of Iran University of Medical Sciences. Iranian J Medical Ethics History Med (Persian); 2009.
Bayazidi S, Zarezadeh Y, Zamanzadeh V, Parvan K. Medication Error Reporting Rate and its Barriers and Facilitators among Nurses. J Caring Sci. 2012;1(4):231-6.
Davis MA, Rake GW. Implementation of a data-based medical event reporting system in U.S. department of defense. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in patient safety: from research to implementation: Vol. 3. Implementation issues. Surveillance. Rockville, MD: Agency for Healthcare Research and Quality; 2005: 235-244.
Bhowmick S, Banerjee K, Sikdar S, Chatterjee TK. An evaluation of knowledge, attitude, and practice of institutional ethics committee members from eastern India regarding ethics committee functioning and pharmacovigilance activities conducted during clinical trials: a pilot study. Perspectives Clin Res. 2014;5(3):115-20.
Guchelaar HJ, Colen HBB, Kalmeijer MD, Hudson PTW, Twiss TIM. Medication Errors Drugs. 2005;65(13):1735-46.
Leape LL, Cullen DJ, Clapp DM. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999;281(3):267-70.
Kucukarslan SN, Peters M, Mlynarek M. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med. 2003;163(17):2014-8.
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