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The Importance of Medication Errors Reporting in Improving the Quality of Clinical Care Services
Nesreen Mohamed Kamal Elden1, Amira Ismail
1Department of Public Health and Community medicine, Faculty of Medicine, Cairo University, Egypt. drn_kamal@yahoo.com.
Introduction:
Medication errors have significant implications on patient safety. Error detection through an active management and effective reporting system discloses medication errors and encourages safe practices.
Objectives:
To improve patient safety through determining and reducing the major causes of medication errors (MEs), after applying tailored preventive strategies.
Methodology:
A pre-test, post-test study was conducted on all inpatients at a 177 bed hospital where all medication procedures in each ward were monitored by a clinical pharmacist. The patient files were reviewed, as well. Error reports were submitted to a hospital multidisciplinary committee to identify major causes of errors. Accordingly, corrective interventions that consisted of targeted training programs for nurses and physicians were conducted.
Results:
Medication errors were higher during ordering/prescription stage (38.1%), followed by administration phase (20.9%). About 45% of errors reached the patients: 43.5% were harmless and 1.4% harmful. 7.7% were potential errors and more than 47% could be prevented. After the intervention, error rates decreased from (6.7%) to (3.6%) (P≤0.001).
Conclusion:
The role of a ward based clinical pharmacist with a hospital multidisciplinary committee was effective in recognizing, designing and implementing tailored interventions for reduction of medication errors. A systematic approach is urgently needed to decrease organizational susceptibility to errors, through providing required resources to monitor, analyze and implement effective interventions.
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