Analysis on reports of medication errors with methotrexate tablets in National Monitoring Network for Clinical Safe Medication from 2012 to 2017

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Objective To understand and analyze the occurrence of medication errors with methotrexate tablets and their related factors in order to avoid or reduce the adverse events occurring. Methods All medication error reports in National Monitoring Network for Clinical Safe Medication from September 22, 2012 to September 21, 2017 were collected and the reports of medication errors with methotrexate tablets were selected. And the grading and content of medication errors with methotrexate tablets, the persons who found medication errors, and the triggering factors for medication errors were analyzed. Results A total of 25 119 reports of medication errors from the 204 hospitals of 25 provinces and municipalities in our country were collected by National Monitoring Network for Clinical Safe Medication between September 22, 2012 and September 21, 2017.The reports of medication errors with methotrexate tablets accounted for 0.14% (35 /25 119) of the total reports of medication errors. The reports of serious medication errors(E-I) with methotrexate tablets accounted for 3.18%(7/220) of the total reports of serious medication errors. The reports of medication errors with methotrexate tablets involved 34 patients, including 16 males and 18 females aged 25-87 years. The 34 patients included 20 cases of rheumatoid arthritis, 6 cases of psoriasis, 2 cases of systemic lupus erythematosus, 2 cases of leukemia, 1 case of connective tissue disease, 1 case of polymyositis, 1 case of hypertension, and 1 case of toxic diffuse goiter. Of the 35 cases of medication errors, 18 cases(51.43%) were classified as class B, 9 cases(25.71%) as class C, 1 case (2.86%) as class D, 1 case(2.86%) as class E, 5 cases(14.28%) as class F, and 1 case(2.86%) as class I. The serious medication errors accounted for 20.00% of medication errors with methotrexate tablets. Four patients had both wrong dose and wrong frequency of administration. Among the medication errors with methotrexate tablets, the frequency of administration errors ranked first, accounting for 53.85%(21/39) in total. All patients mistook once weekly for once daily . Wrong dose ranked the second, accounting for 30.77%(12/39) in total. Wrong drug class ranked the third, accounting for 7.69% (3/39) in total. The persons who triggered the medication errors with methotrexate tablets included doctors 74.29%(26/35), pharmacists 17.14%(6/35), and patients or their family members 8.57% (3/35). Twenty-six cases of medication errors with methotrexate tablets were triggered by doctors, of them, 24 were discovered and intercepted by pharmacists. Of the 6 cases of medication errors triggered by pharmacists, 3 cases were discovered and intercepted by pharmacists, and one case was discovered and intercepted by a doctor. These medication errors did not cause any harm to the patients. Four cases that were not intercepted and 3 cases triggered by patients or their families were all serious medication errors, of which 1 caused death. Of the persons who discovered the medication errors, pharmacists accounted for 77.14% (27/35), and doctors accounted for 22.86% (8/35). The main factors causing medication errors were lack of related pharmacologic knowledge(45.71%, 16/35), copying error(20%, 7/35), similar drug name or adjacent packing boxes (8.57%, 3/35). Conclusions Medication errors with methotrexate tablets often occurred in patients with autoimmune diseases. The content of medication errors with methotrexate tablets mainly due to wrong frequency of administration. The incidence of serious medication errors was high, it might cause death. The main cause of medication errors with methotrexate tablets in treating non-neoplastic diseases was lack of understanding of frequency administration once weekly . Pharmacists might play an important part in detecting and intercepting medication errors with methotrexate tablets. Key words: Methotrexate; Drug interaction; Medication errors; Primary prevention; Frequency of administration