DOI: http://dx.doi.org/10.18203/2319-2003.ijbcp20151365

Medication errors in outpatient setting of a tertiary care hospital: classification and root cause analysis

Sunil Basukala, Sameer Mehrotra, Shiva Devarakonda

Abstract


Background: The goal of drug therapy is the achievement of defined therapeutic outcomes that improve a patient’s quality of life while minimizing patient risk. Medication error is an important cause of morbidity and mortality, yet it can be a confusing and under-appreciated concept.

Methods: A total of 3000 prescriptions were selected using Systematic Random Sampling, and prescription errors were stratified according to nuisance they may cause by dispensation followed by identification of Root Causes of the errors.

Results: Out of a total of 3000 prescriptions, 2394 prescriptions (70.61%) were found to have one or more errors. The total number of errors were 3390 as many prescriptions had more than one error. The most common type of errors was Type D and was found in 70.61% prescriptions.

Conclusions: Learning more about medication errors may enhance health care professionals’ ability to provide safe care to their patients. Hence,  A focus on easy-to-use and inexpensive techniques for medication error reduction should be used to have the greatest impact.


Keywords


Medication errors, Prescription, Root cause analysis

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References


Manasse AP. Repeat prescriptions in general practice. J R Coll Gen Pract. 1974;24(140):203-7.

Murdoch JC. The epidemiology of prescribing in an urban general practice. J R Coll Gen Pract. 1980;30(219):593-602.

Drury VW. Repeat prescribing - a review. J R Coll Gen Pract. 1982;32(234):42-5.

Secretaries of State for Social Services, Wales, Northern Ireland and Scotland. Promoting Better Health (Cm249). London: HMSO; 1987.

Harris CM, Jarman B, Woodman E. Prescribing- Suitable Case for Treatment. Occasional Paper 24. London: Royal College of General Practitioners; 1984.

Harris CM, Fry J, Jarman B, Woodman E. Prescribing – a case for prolonged treatment. J R Coll Gen Pract. 1985;35(275):284 7.

Belknap SM, Moore H, Lanzotti SA, Yarnold PR, Getz M, Deitrick DL, et al. Application of software design principles and debugging methods to an analgesia prescription reduces risk of severe injury from medical use of opioids. Clin Pharmacol Ther. 2008;84(3):385-92.

Merril G. The $800 Million Pill: the Truth behind the Cost of New Drugs. California: University of California Press; 2005.

Budhiraja RD. Manual of Practical Pharmacy. 2nd Edition. Bombay: Bombay Popular Prakashan; 1993.

De Vries TP., editors. Guide to Good Prescribing: a Practical Manual (WHO/DAP/94.11). Geneva: World Health Organization; 1995: 51-5.

ICH. Harmonised Tripartite Guideline for GCP. Geneva: Institute of Clinical Research; 1996.

Aronson JK. Medication errors: what they are, how they happen, and how to avoid them. QJM. 2009;102(8):513-21.

Dean B, Schachter M, Vincent C, Barber N. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care. 2002;11(4):340-4.

Davis K, Schoenbaum SC, Collins KS, Tenney K, Hughes DL, Audet AJ. Room for Improvement: patients Report on the Quality of their Health Care.

LaPointe NM, Jollis JG. Medication errors in hospitalized cardiovascular patients. Arch Intern Med. 2003;163(12):1461-6.

Neville RG, Robertson F, Livingstone S, Crombie IK. A classification of prescription errors. J R Coll Gen Pract. 1989;39(320):110-2.

Mullan K. Importance of legible prescriptions. J R Coll Gen Pract. 1989;39(325):347-8.

Shulman R, Singer M, Goldstone J, Bellingan G. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care. 2005;9(5):R516-21.

A Call to Action: eliminate Handwritten Prescriptions within 3 Years. Electronic Prescribing Can Reduce Medication Errors (White Papers from the Institute for Safe Medication Practices).