PMU12 - Stewardship of Medication Errors in A Developing Country’s Scenario: A Clinical Pharmacist’s Role

Abstract

To establish medication error reporting and monitoring programme in a tertiary care teaching hospital A prospective cohort study was conducted among patients aged ≥ 18 years hospitalised in a south Indian hospital over three years. On a daily basis, patients, patient's caregivers, and health care professionals (HCPs) were interviewed about the medication use process and patients' notes reviewed for identifying and evaluating outcomes of ME using the NCC MERP and Prevention standards. Root cause analysis was performed to understand the reasons and discussed with the relevant HCP to minimise the likelihood of recurrence of the ME. A total of 1310 medication errors were reported among 20256 patients hospitalised and the incidences 6.4%. Aetiologies of reported MEs were administration errors 501(38.2%), prescribing and transcribing errors totalling to 363 (28%), following dispensing and medication procurement errors 223 (17%) each. Clinical Pharmacists, nurses and doctors reported 674 (51%), 409 (31%) and 227 (17%) respectively. A majority of reported medication errors had an outcome of Category A, 432 (33%) followed by category B, 413 (32%). Root-cause of these MEs were distractions, workload, and communications with 472, 422, and 341 errors reported respectively. Analgesics (19.4%) and antibiotics (15.7%) were the most commonly implicated classes of medications. The length of hospital stays, OR 2.31 (1.22–4.36), the number of medications OR 2.30 (1.4 – 3.5), multiple comorbidities OR 1.79 (0.48-6.68), and work shifts OR 2.359 (1.233 - 4.514) were found to be significant predisposing factors at 95% CI. Medication error reporting system can contribute significantly towards the patient safety when all stakeholders are actively involved. Non-punitive systems need to be enforced strictly without compromising on personnel involved in redundant medication errors. Clinical Pharmacists can provide excellent support in sustaining and promoting patient safety when worked along with other health care professionals.