Effective implementations to reduce medication administration errors in a tertiary care teaching hospital

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Background: Medication Administration Errors (MAEs) can lead to unmet therapeutic objectives as these errors can directly harm the patient and affect the outcome of therapy. Materials and Methods: This was an implementation research planned to evaluate the effect of interventions on the prevalence and severity of MAEs over three years, from 2020 to 2022, at a tertiary care hospital where clinical pharmacists were allotted to look into medication-related activities. Amedication error reporting form, developed by the pharmacologist, was used to collect MAE data. Analysis of this information aided in the planning of interventions to curtail the occurrence of such errors in the future. Interventions included drug and disease education leaflets, bedside training, vial/ampoule reading training, understanding different dose strengths, maintaining patient bedside boxes, antibiotic reconstitution leaflets for reference, and charts to guide safe drug administration. Results: The effect of these interventions was analyzed at the end of each year on the prevalence and nature of MAEs, where a decline of 38.97% was found in 2021 and a further 34.88% in 2022, considering the number of opportunities. The most prevalent was the wrong dose (~57%) errors commonly found with oral solid dosage forms and the cardiovascular group of drugs (42.5%). These MAEs were mainly of no harm category C (64%), while only 1.5% of them had caused harm (category E) to the patient, but none of these was sentinel. Conclusion: Interventions by clinical pharmacists successfully helped reduce MAEs and prevented patient harm in the further study period.