(P-093) Analysis of Voluntarily Reported Medication Errors: An Excerpt from a Teaching Hospital in a Developing Country

Background: Iatrogenesis is an inevitable reality in the current health care framework. Medication errors (ME) jeopardizes patient safety. It is important to understand how often and why these errors are occurring to develop interventions and to prevent their occurrence in a developing nation.

Objectives: To determine the incidence, causes, pattern and outcomes of medication errors in a tertiary care hospital.

Methods: The ME reporting system was established using the principles based on prospective, voluntary, open, anonymous and stand-alone surveillance. MEs reported by the healthcare professionals for the year 2019 were considered for the review. The reporters were given the choice to remain anonymous. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)’s categories of outcome was used. Categorical analysis was carried out to determine the patterns, causes and outcomes of the reported errors.

Results: A total of 739 Medication Errors were reported [478 (64%) were male and 261 (36%) were females] in the calendar year 2019. Of which, Doctors [360 (49%)] reported majority of the MEs followed by Nurses [334 (45%)] and Pharmacists [45 (6%)]. Majority [696 (94%)] of these MEs occurred in the wards. Documentation errors [313 (42%)] were the most common type of MEs followed by administration errors [190 (26%)], prescription errors [90 (12%)], dispensing errors [53 (7%)], and rest procurement related errors. Documentation errors constituted improper-documentation [165 (52%)] and incomplete-documentation [148 (48%)]. While, omission error constituted [76 (40%)] majority amongst medication-administration errors. Majority of the contributing factors were excessive workload, fatigue, unclear inter-personnel communications and patient-related factors accounted for 38%, 13.1%, 9.6% and 7.7% respectively. The majority of the reported MEs had an outcome of category C [391 (52%)] and B [260 (35%)].

Conclusions: Clinical Pharmacist-initiated patient safety programme was accepted by HCPs and voluntarily reported. Although the majority of MEs that reached the patients did not cause any harm, it is important to erect necessary barriers to prevent MEs from occurring. Emphasizing that ME reporting is not fault finding but is essential for heightened acceptance.