Prescribing errors incidence in hospitalized Saudi patients: Methodology considerations

Abstract

Medication errors are the leading cause of adverse drug events (ADEs) and most commonly occur in the prescribing stage (Bates et al., 1995; Aljadhey et al., 2013). A systematic review of 65 studies that investigated the prevalence and incidence of prescribing errors conducted in 2009 in the UK concluded that prescribing errors occur in 7% of medication orders, 2% of patient days and 50% of hospital admissions (Lewis et al., 2009). In Saudi Arabia majority of the studies conducted to investigate prescribing errors came from the primary care settings. However, hospitalized patients received little attention. A recent study conducted for two months in the inpatient medical wards of a teaching hospital in Riyadh city found an incidence of 7.7% prescribing errors in 1582 written medication orders, with the wrong strength and wrong drug administration frequency accounting for the most common type of errors identified (Al-Dhawailie, 2011). A prescribing error in this study was defined as wrong drug, wrong dose, wrong strength, wrong frequency and wrong drug combination. This study provided an example of the severity of the prescribing errors, however how the author concludes that, was not clearly defined. Other investigators conducted a study to identify prescribing errors in the general pediatric wards and a pediatric intensive care unit of a tertiary hospital (Al-Jeraisy et al. (2011)). A prescription error in this study was defined as; incorrect or inappropriate drug selection, dose, route, rate of administration, or frequency. Prescription errors also include; illegible handwriting, an incomplete order (missing the dose, route, or frequency), incompatibility, incorrect instructions for using the drug product, and the use of non-standard nomenclature or abbreviations, that requires further interpretation. Investigators reviewed 2380 medication orders and identified 56 prescribing errors per 100 medication orders (95% CI: 54.2%, 57.8%) and the majority of these errors (79%) were classified as potentially harmful. However, the contexts based on which the severity of these errors was defined were also not clearly defined. There are obvious variations in the definitions and methods used to detect these errors, and hence there is remarkable variability in the reported incidence. These variations may also reflect the quality of the particular healthcare settings. To our knowledge the previously mentioned two studies are the only published studies that investigated the in hospital incidence of prescribing errors in Saudi Arabia and therefore their finding is only a snapshot of a specific ward within a single hospital in the country. Therefore; the results of these studies are not generalizable. In the systematic review conducted by Lewis et al. (2009), most of the studies that investigated prescribing errors have either used their own definitions based on the commonly known types of medication errors, or have used a standard and validated definition that was developed by Dean et al., (2000), who defined prescribing errors as; “A clinically meaningful prescribing error occurs when, as a result of a prescribing decision or prescription writing process, there is an unintentional significant (1) reduction in the probability of treatment being timely and effective or (2) increase in the risk of harm when compared with generally accepted practice”. This definition was also accompanied with different scenarios that represent prescribing errors. However, other investigators argued that it is also important to include insignificant prescribing errors that did not cause harm, because it might cause harm in the future (Jeffrey, 2009). In Saudi Arabia, a large study at a national level from different hospitals that uses a standard and validated definition of prescribing errors is needed. The use of a pre-validated definition is strongly supported to allow comparison of data between studies from different parts of the world that use the same methodology. Perhaps if we utilize the widely used and previously validated definition and scenarios that represent prescribing errors (Dean et al., 2000), revalidation of the tool in the context of Saudi Arabia might be an essential step. This will help in getting generalizable results and will also help when comparing our local data with international studies that had used similar definitions.