Medication Error Reporting Research Articles

Development and Interrater Agreement of a Novel Classification System Combining Medical and Surgical Adverse Event Reporting

Categorization systems for adverse events are not standardized across care settings and specialties and do not always include near miss events (events where there was potential for patient harm, but where no actual harm occurred), making it difficult to effectively assess patient safety for quality improvement. To develop and assess interrater agreement on a classification system for adverse events reporting that incorporates events in both inpatient and outpatient settings across medical and surgical subspecialties including near miss events. A cross-sectional study in a tertiary care center including 174 patient cases occurring from 2018 to 2020 was carried out. Data were abstracted from a Department of Otorhinolaryngology-Head and Neck Surgery Quality Assurance database. The cases were comprised of near miss and adverse events occurring in adult and pediatric patients in inpatient, outpatient, and emergency department settings. The ratings took place in March and April of 2022. Four raters (2 attending physicians and 2 senior resident physicians) were recruited to classify these cases according to 3 classification systems: the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), Clavien-Dindo, and our novel Quality Improvement Classification System (QICS). The primary outcome was overall interrater agreements using Fleiss κ. Across all 4 raters grading 174 cases, the NCC-MERP, Clavien-Dindo, and QICS received a κ score. Fair-to-moderate interrater reliability was observed between the resident and attending physician groups across the 3 classification systems: NCC-MERP (κ = 0.33; 95% CI, 0.30-0.35), Clavien-Dindo (κ = 0.47; 95% CI, 0.43-0.50), and QICS (κ = 0.42; 95% CI, 0.39-0.44). Strong interrater concordance was observed for complications across all scenarios. This cross-sectional study found that the new QICS classification scheme was applicable to wide-ranging clinical scenarios with a focus on patient-centered outcomes including near miss events. In addition, QICS allowed for the comparison of patient outcome data in a multitude of settings.

Types, trends, and patterns of the reported antimicrobial errors to the eastern region’s medical centers in Saudi Arabia: A cross-sectional study

IntroductionMedication errors (MEs) are a huge burden on any healthcare system and have been associated with significant morbidity and mortality. The medical literature reported heavily on MEs but lacked focus on analyzing high-risk medications such as antimicrobials. Research design and methodsThis was a retrospective analysis of the MEs database reported by the eastern region’s medical centers in Saudi Arabia from January 1, 2019 to December 31, 2019. We used descriptive analysis to identify most common antimicrobials with errors, the stage of antimicrobial errors, type of the errors, contributing factors to the errors, and categories of errors based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) classification of errors. ResultsA total of 1422 (22.1%) antimicrobial errors were identified out of 6412 MEs. Amoxicillin/Clavulanate (18%) was the most common antimicrobial reported in the database. Most errors occurred in the prescribing phase (87.6%) and included mainly incorrect doses (32.1%) and duplicate therapy (20.5%). In addition, most errors were identified as category B (72.5%). Finally, inexperienced personnel (57.9%) was the most cited contributing factor. ConclusionThis study revealed that antimicrobial errors occur primarily during prescription and that policy gaps and inexperienced staff were contributory factors. To improve, the focus should shift to physician education, clear dosing guidelines, efficient workload management, and implementing antimicrobial stewardship programs to promote appropriate antimicrobial use.

Thực trạng báo cáo sự cố y khoa và một số yếu tố ảnh hưởng tại bệnh viện C Đà Nẵng năm 2021 - 2022

This study describes the current situation of medical error reporting and some influencing factors at C Hospital in Da Nang in 2021-2022. Secondary data from 269 error reports were analyzed and 12 in-depth interviews and 3 focus group discussions were conducted. Results showed that 72,1% risk cases and 27,9% of errors had occurred; Nurses reported errors (89,2%); Most errors were reported by clinical units (88,8%); Report a problem after 24 hours (67,3%); Some health workers have limited knowledge, are afraid of reporting, and report errors not on time; Operations manager reported medical errors well; Simple process that is easy to implement; Error reporting is encouraged; Training has not yet reached all staff. Keywords: Medical error report, influencing factors, C Hospital Da Nang

The accuracy of the Global Trigger Tool is higher for the identification of adverse events of greater harm: a diagnostic test study.

Global Trigger Tool (GTT) of the Institute for Healthcare Improvement (IHI) has been used as a measurement strategy for patient safety by several institutions and national programs. Although the greater ability of the GTT to identify adverse events (AEs) compared to other methods has already been demonstrated, there are few data on its accuracy, and studies suggest lower sensitivity for minor AEs. This study aimed to assess the accuracy of the GTT for identifying AEs in adult inpatients for all AEs and for the subgroup of AEs with greater harm to the patient, classified as F-I on the IHI-GTT adapted version of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Errors. In this diagnostic test study, GTT is the index test and identification of AEs (yes/no) represents the condition of interest. Due to the lack of a gold standard test, a composite reference standard method was developed. Reference standard method combined real-time (during hospitalizations) and retrospective search of medical records and administrative data for screening criteria and AEs. Both tests were applied to a random sample of 211 hospitalizations of adult inpatients during October-November 2016 in a large public hospital in Belo Horizonte, Brazil. The accuracy of the GTT was evaluated using sensitivity, specificity, and global accuracy. A total of 176 AEs were identified in 67 admissions using reference standard method and 129 AEs in 76 admissions using GTT, resulting in rates of 126 and 93 AEs/1000 patient-days, respectively. Sensitivity, specificity, and global accuracy of the GTT for the identification of individual AEs were, respectively, 0.41 (95% confidence interval [CI] 0.34; 0.49), 0.68 (95% CI 0.60; 0.74), and 0.54 (95% CI 0.49; 0.60) for all AEs, regardless of the harm categorization, and 0.85 (95% CI 0.72; 0.93), 0.88 (95% CI 0.82; 0.92), and 0.87 (95% CI 0.82; 0.91) for the subgroup of AEs categorized as harm F-I. Among the main AEs missed by the GTT are AEs related to nursing care, such as those related to peripheral venous access and gastric/enteric catheters. GTT proved to be a valid method for identifying AEs in adult inpatients. Its accuracy increases when minor harm AEs are not counted. Among the main AEs missed by the GTT are those related to nursing care. Therefore, the GTT should be used in conjunction with other measurement strategies to achieve results that are representative of the quality profile of the care provided and, thus, guide the best improvement strategies.

Analysis of Medication Errors Reported by Community Pharmacists in the Republic of Korea: A Cross-Sectional Study

Background and objectives: We aimed to describe medication-related incidents or medication errors (MEs) reported by community pharmacists and analyze the prevalent medications involved. Materials and Methods: We extracted ME reports from databases comprising patient safety incidents reported to the Korean Pharmaceutical Association between January 2013 and June 2021. Medications were analyzed according to the second (therapeutic subgroup) and fifth (chemical substance) levels of the Anatomical Therapeutic Chemical classification. Results: A total of 9046 MEs were identified, most of which were near miss reports (88.3%). Among the errors that reached the patients (521 cases), harmful incidents accounted for 76.8%. Most MEs occurred during prescription (89.5%), while harmful MEs occurred mainly during dispensing (73.3%). In the prescription step, wrong drugs (44.8%), dosing errors (27.0%), and wrong durations (14.0%) were common. Anti-inflammatory and anti-rheumatic products (M01), drugs for acid-related disorders (A02), and antihistamines for systemic use (R06) were the most frequently reported medication classes involved. Harmful incidents were most common for dosing errors (31.0%) and wrong drugs (26.8%) and were common with warfarin, levothyroxine, and glimepiride. Conclusions: The MEs reported by community pharmacists were mainly prescribing errors, most of which were rectified before reaching patients. The prevalent medications involved in harmful errors include anti-diabetic, anti-thrombotic, and anti-inflammatory agents.

Evaluation of pattern of medication errors in a tertiary care hospital in South India: A prospective observational study

Background: Medication errors (MEs) increase morbidity, mortality, and economic burden to health-care system. MEs are the sixth highest cause of death in America. Documented data, studies, and reporting of MEs in India are limited. Aims and Objectives: The study was undertaken with the objectives to determine (a) the frequency of MEs and (b) the nature of MEs in the hospital. Materials and Methods: A prospective observational study of 6-month duration was conducted using prescriptions (n = 1007) of patients admitted as inpatients in wards and intensive care unit in the hospital. Sensitization programs were regularly carried out to health-care professionals. The case records and treatment charts of patients in wards were reviewed and the patients or caretakers were interviewed to gather information. Standard hospital pro forma for MEs was used to collect data on MEs. Data were analyzed using descriptive statistics in Excel. Results: Overall, ME rate was 26.81% in the 6 months with a declining trend from the initial 36.11% month of study period. Prescription, dispensing, administration, and documentation errors were, respectively, 92.2%, 4.1%, 3.3%, and 17.8%. Errors pertaining to writing generic names, doses, and routes of drug administration were, respectively, 73%, 48.5%, and 35.2%. Majority (94.8%) of ME belonged to category B of the National Coordinating Council for Medication Error Reporting and Prevention index. Conclusion: The current study observed a high prescription error rate in hospital emphasizing the need for ME sensitization/training program to doctors and nurses. The study observed a declining trend in ME rate that would be attributed to the ongoing sensitization program. The study also indicates an enhanced requirement for the implementation of regular and rigorous reporting system in the hospital.

Use of Web-Based Medication Error Reporting and Management Systems in Improving Medication Safety in Assisted Living Facilities: A Systematic Review

Use of Web-Based Medication Error Reporting and Management Systems in Improving Medication Safety in Assisted Living Facilities: A Systematic Review

Identification and Characterization of Preventable Adverse Drug Events in Family Medicine Clinics from Central Saudi Arabia.

Medication errors can result in adverse drug events (ADEs) and cause considerable patient harm. Limited data are available from Saudi Arabia and the Middle East regarding the prevalence of preventable adverse drug events (pADEs) in primary care settings. To estimate the period prevalence of pADEs and assess the medication error severity in primary care setting in Saudi Arabia. This retrospective study is a continuation of a previous study where 117 of 2000 adult patients managed at the Family Medicine clinics of King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, were identified to have had least one medication error in the past 15 months. The electronic health records of these 117 patients were analyzed for a 3-month post-medication error period to explore the presence of pADE. Medication errors were categorized according to the National Coordinating Council for Medication Error Reporting and Prevention index (NCC MERP) and the occurrence of pADE was assessed using the NCC MERP scheme. Of the included 117 patients, 9 (7.7% [95% confidence interval (CI): 2.79-12.59]) experienced pADE (Category E), while 108 (92.3% [95% CI: 87.97-98.35]) did not (Category C). All patients who experienced pADE were using over-the-counter medications and were on polypharmacy. Outcomes 2a and 2b (asthma and β-blocker) accounted for two and four cases, respectively, while Outcomes 6 (warfarin and international normalized ratio), 7 (lithium and lithium level), 16 (new oral anti-coagulant or warfarin and antiplatelet), and 17 (acetylsalicylic acid [aspirin] and antiplatelet) each accounted for one case. This study provides the period prevalence of patients with pADEs from Family Medicine clinics at a major tertiary hospital of Saudi Arabia, and highlights the need for a multicenter study of clinically important medication errors at the prescribing and monitoring stages for the development of quality improvement programs.

The Identification and Analysis of Adverse Events in Elderly Female Breast Cancer Patients Using Anthracycline-Based Regimens at Dharmais Cancer Hospital

Background: Anthracycline is the first-choice chemotherapy for the treatment of breast cancer, particularly in elderly patients. However, several studies reported adverse events in the treatment of using anthracyclines. This study aims to identify adverse events. It is also to find out more about how independent variables are related to adverse events. Method: An observational retrospective study of elderly patients (≥ 60 years old) was conducted in a tertiary cancer hospital in Jakarta. Data were collected from January 2018 to December 2020. We used an oncology-specific trigger tool to identify adverse events during anthracycline-based regimens. Independent variables were evaluated in univariate analysis: age, weight loss, marital status, total cumulative dose, polypharmacy, types of anthracyclines, and metastatic status. Bivariate and multivariate analyses were conducted to find out the relationship between the independent variables and adverse events.Results: In total, 107 subject records were collected and reviewed. Triggers were identified 122 times in 86 medical records. Blood transfusion, the most common trigger, was found in 35% of subjects. We found the number of triggers and adverse events more commonly identified in the first and second cycles of chemotherapy. The prevalence of adverse events is detected in 80% of subjects. Of these 86 subjects, 74% were detected in doxorubicin and 26% were detected in epirubicin. All the adverse events were categorized as The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) harm category E.Conclusion: Trigger tools specific for cancer patients can be used to identify adverse events. Blood transfusion was the common trigger to detect adverse events in our study. Adverse events with category E were identified in all the subjects. Neutropenia and anemia were the most common adverse events in all cycles of chemotherapy. Weight loss was the independent variable related to adverse events in elderly breast cancer patients (p <0.003).

Detection and Prevention of Medication Errors by the Network of Sentinel Pharmacies in a Southern European Region

A medication error (ME) is a drug-related problem that has been recognized as a common and serious threat to patient safety. The aim of this study was to detect and analyze ME reports occurring throughout the therapeutic process through the community's pharmacies in order to improve the efficacy and safety of medications and contribute to the prevention of future MEs. This was a three-year descriptive, observational, and prospective study to detect and analyze the different MEs reported by the Catalan sentinel pharmacies network (Catalan SePhaNet). In total, 1394 notifications of MEs were reported (an incidence rate of 737.34 cases/100,000 inhabitants). MEs were detected more frequently in primary care centers. Most of the MEs reported were caused by an incorrect, incomplete, illegible, or verbal medical prescription (41.3%). Of the global notifications detected, 71.9% did not reach the patient (categories A and B). The drugs most frequently implicated in the reported ME cases were beta-lactam antibiotics. In 6.0% of the cases, the ME caused injury to the patient (categories E and F). In 72.0% of the global notifications, a pharmacist's intervention avoided the ME. The importance of a community pharmacy and the role of a pharmacist were demonstrated in aspects related to patient and drug safety.

Medication administration errors reporting by Neonatal Intensive Care Nurses in Malaysia: A nationwide study

Aim: To determine the willingness and barriers of Neonatal Intensive Care Unit (NICU)-based nurses in Malaysian hospitals in reporting medication errors. Background: Reporting incidents is important in improving patients’ safety and developing a healthy culture of learning from mistakes. Method: Three self-developed scenarios, ranging from mild, moderate to severe medication administration errors, were used to identify nurses’ willingness to report an error. A validated questionnaire assessing barriers to reporting errors was adapted. The sample size calculated was 139. All 22 NICUs in government-funded hospitals were approached. Nurses were randomly recruited and given a URL to access the online questionnaire. Results: Of 182 nurses from 15 hospitals who participated, 91.2% (n=166) were willing to report medication errors and patient safety was the main concern to report it. Among the nurses (n=16, 8.8%) who chose not to report medication errors, they were worried about getting into trouble (87.5%), information being shared with managers (56.3%), disciplinary actions and medico-legal issues (50.0%). Conclusion: Most NICU nurses were willing to report a medication error, and the barriers to the minority of them not reporting should be given attention. Implications: Reassurance by the managers for not penalizing the nurses who report an error should be emphasized in the incident reporting policy.

Negative emotions experienced by healthcare staff following medication administration errors: a descriptive study using text-mining and content analysis of incident data

BackgroundMedication errors regardless of the degree of patient harm can have a negative emotional impact on the healthcare staff involved. The potential for self-victimization of healthcare staff following medication errors can add to the moral distress of healthcare staff. The stigma associated with errors and their disclosure often haunts healthcare professionals, leading them to question their own professional competence. This paper investigates the negative emotions expressed by healthcare staff in their reported medication administration error incidents along with the immediate responses they received from their seniors and colleagues after the incident.MethodThis is a retrospective study using a qualitative descriptive design and text mining. This study includes free-text descriptions of medication administration error incidents (n = 72,390) reported to National Reporting & Learning System in 2016 from England and Wales. Text-mining by SAS text miner and content analysis was used to analyse the data.ResultsAnalysis of data led to the extraction of 93 initial codes and two categories i.e., 1) negative emotions expressed by healthcare staff which included 4 sub-categories of feelings: (i) fear; (ii) disturbed; (iii) sadness; (iv) guilt and 2) Immediate response from seniors and colleagues which included 2 sub-categories: (i) Reassurance and support and (ii) Guidance on what to do after an error.ConclusionNegative emotions expressed by healthcare staff when reporting medication errors could be a catalyst for learning and system change. However, negative emotions when internalized as fear, guilt, or self-blame, could have a negative impact on the mental health of individuals concerned, reporting culture, and opportunities for learning from the error. Findings from this study, hence, call for future research to investigate the impact of negative emotions on healthcare staff well-being and identify ways to mitigate these in practice.

Medication administration errors and associated factors among nurses in Addis Ababa federal hospitals, Ethiopia: a hospital-based cross-sectional study

ObjectiveThis study was conducted to assess the magnitude and contributing factors of medication administration errors among nurses in federal hospitals in Addis Ababa, Ethiopia.DesignA hospital-based cross-sectional study design was employed....

Serious Cardiovascular Adverse Event Associated with Hydroxychloroquine with Azithromycin in Patient with COVID-19 : A Pharmacovigilance Analysis of the FDA Adverse Event Reporting System (FAERS)

The use of Hydroxychloroquine combine with Azythromycin for the treatment of coronavirus disease (COVID-19) it may increases the risk of serious cardiovascular advere events. WHO not recommended for the use of HCQ to treat the COVID-19 because it has serious side effect on heart like Arrhythmia ,cardiac toxicity. In the following describe the risk of serious cardiovascular adverse event using HCQ is combined with Azythromycin it compared with that therapeutic alternatives. Some clinical trial that reporting the combine of HCQ with AZ demonstrated better efficacy than signal drug combination of HCQ and AZ has synergestic effect against viral infectious. The FAERS that evaluate adverse effect reports ,medication error reports and product quality complaint resulting in adverse effect that were submitted to FDA. The performing the test to analysis to case series using the US FDA Adverse Event Reporting System(FAERS).

A Retrospective Analysis of Medication Errors at a Tertiary Hospital in a Northern State of Malaysia

Medication errors (MEs) have been recognised as a global issue. The occurrence of MEs can lead to serious clinical outcomes and represents a significant concern for healthcare providers and policymakers. This study aims to analyse the characteristics and pattern of MEs reported at Hospital Raja Permaisuri Bainun (HRPB), Ipoh in 2019. This study was conducted by reviewing ME reports at the HRPB from 1 January 2019 to 31 December 2019. A total of 1,066 ME reports were received by the Drug Information Centre (DIC) of the HRPB in 2019. However, only 1,045 reports that fulfilled the inclusion and exclusion criteria were reviewed. From these reports, 97.5% of errors were classified as near-misses. The actual error rate is only 2.5%. More than four-fifth of the overall reports originated from the wards (91.1%). The mean age of the patients exposed to MEs was 47.64 ± 24.32 years. Collectively, the geriatrics patients were the largest identified group that encountered MEs (n = 387, 37.1%). The prescribing stage accounted (97.4%) for almost all the MEs. Cases of wrong dose (52.3%) contributed to more than half of the overall error. About 99.4% of the errors had no harmful effect on the patient’s health conditions. The cardiovascular system (25.0%) was the most common drug class involved in ME. Staff factor was believed to be the principal contributing factors that lead to MEs. Majority of the MEs were detected and reported by the pharmacist. Effective implementation of proper guidelines and existing preventive strategies would help in reducing and eliminating MEs, thus improving clinical practices and ensure patients’ safety.

Cross-Sectional Study on the Attitude and Perception of Healthcare Practitioners Towards Medication Errors in a Nigerian Tertiary Hospital

This study was carried out to evaluate the attitude and perception of healthcare professionals towards medication errors. A cross-sectional study was carried out using a semi-structured questionnaire administered to nurses, pharmacists and physicians at the University College Hospital of Ibadan, Nigeria. Data were analysed with descriptive and inferential statistics. Most of the study participants, 444 (55.5%) and 472 (59.0%) had excellent attitudes and perceptions of medication errors, respectively. Most of the healthcare practitioners (89.1% nurses, 71.8% pharmacists and 66.7% physicians) disagreed with the statement that medication errors are unavoidable and are merely expected daily mistakes. It was observed that 35.5%, 37.6% and 66.7% of the nurses and pharmacists, and physicians, respectively, agreed with the statement that persons responsible for medication errors should be liable for legal actions. Suggestions made by the healthcare professionals on measures to prevent medication errors included recruitment of new staff to increase staff strength (32.8%), training on medication errors (21.4%) and legible handwriting of prescribers (9.4%). The prevalence of unreported medication errors by the study participants was 24.9%. Reasons for not reporting medication error committed included that it was trivial and had no adverse effect on the patient (32.3%), excess workload (26.9%) and fear of reprimand (17.7%). The healthcare professionals displayed excellent attitudes and perceptions of medication errors. An increase in staff strength and training on medication errors were major measures suggested by the study participants to prevent medication errors.

Drug-Related Problems in Bariatric Surgery: a Retrospective Study.

With the rapid increase of bariatric surgery worldwide, drug-related problems (DRPs) in this area seem to be rising. This study aimed to investigate the incidence and characteristics of DRPs in patients undergoing bariatric surgery. Medication records for patients who underwent bariatric surgery were analysed retrospectively between January 2019 and December 2020 in our center. We classified and analysed DRPs using the Pharmaceutical Care Network Europe classification (PCNE version 9.0). Rating severity of these DRPs was based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) classification. Continuous variables were analysed by Student's t-test, and categorical variables were compared using the chi-square test. One-way ANOVA was used to compare the numbers of DRPs. Totally 347 patients were reviewed, and 760 DRPs were identified with an average of 2.19 ± 1.36 DRPs for each patient. The most common DRPs were problems related to perioperative antibiotics accounting for 29.47%, 25.62% and 14.34% for hepatoprotection and proton-pump inhibitors (PPI), respectively. The leading causes of DRPs were inappropriate medications for antibiotics, hepatoprotection, ancillary drugs and PPI. 89.34% of the DRPs were rated at severity categories B-D (which means potential adverse reactions that may occur), whereas 10.66% were rated as categories E-H. There were relations between DRPs and older (32.22 ± 9.29 vs. 29.11 ± 6.53years), fewer concomitant surgeries (1.89 ± 1.25 vs. 2.99 ± 1.31), longer postoperative fasting time (PFT) (1.18 ± 0.55 vs. 1.06 ± 0.24days) and more comorbidities (6.71 ± 2.63 vs. 5.23 ± 1.46) (P < 0.05). The incidence of DRPs in the perioperative period of bariatric surgery is high. Patients with fewer concomitant surgeries and longer PFT are prone to DRPs. It is necessary for clinical pharmacists to participate in medication monitoring and reviewing to facilitate enhanced recovery after bariatric surgery.

Prevalence, Causes and Severity of Medication Administration Errors in the Neonatal Intensive Care Unit: A Systematic Review and Meta-Analysis.

Neonates are at greater risk of preventable adverse drug events as compared to children and adults. This study aimed to estimate and critically appraise the evidence on the prevalence, causes and severity of medication administration errors (MAEs) amongst neonates in Neonatal Intensive Care Units (NICUs). A systematic review and meta-analysis was conducted by searching nine electronic databases and the grey literature for studies, without language and publication date restrictions. The pooled prevalence of MAEs was estimated using a random-effects model. Data on error causation were synthesised using Reason's model of accident causation. Twenty unique studies were included. Amongst direct observation studies reporting total opportunity for errors as the denominator for MAEs, the pooled prevalence was 59.3% (95% confidence interval [CI] 35.4-81.3, I2 = 99.5%). Whereas, the non-direct observation studies reporting medication error reports as the denominator yielded a pooled prevalence of 64.8% (95% CI 46.6-81.1, I2 = 98.2%). The common reported causes were error-provoking environments (five studies), while active failures were reported by three studies. Only three studies examined the severity of MAEs, and each utilised a different method of assessment. This is the first comprehensive systematic review and meta-analysis estimating the prevalence, causes and severity of MAEs amongst neonates. There is a need to improve the quality and reporting of studies to produce a better estimate of the prevalence of MAEs amongst neonates. Important targets such as wrong administration-technique, wrong drug-preparation and wrong time errors have been identified to guide the implementation of remedial measures.

Seven Rights of Medication Administration: Nurses' Knowledge, Attitude, and Compliance

Medication error becomes one of the main concerns in ensuring patient safety. In 2020, X Hospital reported medication error incidents. Although categorized near miss, the incidents should have been prevented. One of the methods to prevent medication errors is by applying the seven rights of medication administration. This study aimed to identify the inhibiting factors in the implementation of the seven rights of medication administration in X Hospital and obtain alternative solutions to those obstacles. This study used an analytic observational design with a cross-sectional design. Data were collected from observations and a survey. Observations and a survey through questionnaires to 20 nurses at X Hospital were made to see the implementation of the procedure. At the end of the data collection, interviews were conducted to find out the obstacles in the inpatient installation in applying the seven rights of medication administration. The results show that the main root causes of medication administration errors were the standard operating procedure (SOP) that has not been standardized and nurses' non-compliance behavior on the seven rights procedure. To resolve medication administration errors, the hospital manager should revise the SOP, conduct internal workshops, and perform scheduled supervision to the nurses.

Knowledge, attitudes and practices of clinical pharmacists to medication error reporting in ministry of health and population hospitals in Egypt

Objective This study aimed to assess the knowledge, attitudes and practices toward medication errors (MEs) reporting among pharmacists working in Ministry of Health and Population (MOHP) hospitals in Alexandria. Methods A cross-sectional study was conducted among all pharmacists who are responsible for reporting medication errors in the Egyptian online reporting system (NO HARMe). Results The majority of pharmacists received training on MEs reporting using the Egyptian online reporting system. Around half of the pharmacists knew the correct definition for medication errors. All respondents were aware of the presence of a MEs reporting system in Egypt. Clinical pharmacists’ attitudes towards MEs reporting was favorable with an overall mean score of 4.20 ± 0.73 in a score ranging from 1 (most unfavorable attitudes score) to 5 (most favorable score). Only 60.7% of the surveyed pharmacists used the system to report MEs. Antibiotics were the most frequent drug category reported and the prescribing stage was the stage in which pharmacists perceived the greatest volume of reports were made (89.3% and 71.4%, respectively). Lack of time was the most frequently identified barrier to reporting, followed by lack of feedback to the report submitted (73.2%, 54.5%, respectively). Inconsistent with the results of other studies, fear from legal consequences and being recognized as an incompetent provider was reported by only 12.5% and 11.6% of pharmacists, respectively. Conclusion The majority of pharmacists have good knowledge and favorable attitudes towards medication error reporting, however around two fifths do not report medication errors.