An Analysis of Medication Errors in a Tertiary Care Teaching Hospital

• Main Authors: Manasij Mitra, Maitraye Basu
• Format: Article
• Language: English
• Published: Amber Publication 2020-06-01
• Series: Journal of Research in Medical and Dental Science
• Subjects: medication errors; near miss; “swiss-cheese” model; safe medication practices
• Online Access: https://www.jrmds.in/articles/an-analysis-of-medication-errors-in-a-tertiary-care-teaching-hospital.pdf

Introduction: Medication errors can occur at any step while handling a medication from prescribing, indenting, dispensing to administration. Medication errors have the potential to cause patient harm to the extent of serious morbidity or even mortality and can have a substantial cost impact on the healthcare system. It can also lead to patient dissatisfaction and loss of confidence on the medical care. This study done with the objective of analysis of medication errors in a teaching hospital with an aim towards process improvement is thus justified. Materials and methods: This were a retrospective study done on the reported inpatient Medication Errors between January 2018 to December 2019 in a 600-bed tertiary care teaching hospital in Bihar. The total number of Medication errors reported during the study period was 1501 and the total number of orders during the said period was 28,472 as retrieved from the pharmacy software. The data from the Incident Report Form was entered in the Excel Spreadsheet and variables analysed using Descriptive Statistics. Results: The medication error rate per 100 orders was 5.27. Majority of the Medication errors about 96.8% took place in the Wards. Majority of the Medication Errors i.e. 66.42% occurred between 4 PM to 8 PM. Doctors contributed to the maximum percentage of Medication Errors 69.8%. Majority of the medication errors 67.62% (1015) were a combination of prescription and transcription errors. The major reasons for Medication Errors were Dose related errors which constituted the maximum proportion of 70.43% (1058). Conclusion: The study concluded that medication errors occur even in hospital settings with established policies for Safe Handling and Use of Medications. However, those can be restricted from reaching the patient with well-structured dedicated strategies and multi-level checks (“Swiss-cheese” Model) in place aimed towards increasing the safety of medication handling and use. Further in-depth studies are recommended on medication errors including “Near miss” which can throw more light on lapses in an existing process and identify the effective intervention strategies to help process improvement.