Pharmacist-Initiated Medication Error-Reporting and Monitoring Programme in a Developing Country Scenario

Area of Science:

• Healthcare Quality Improvement
• Patient Safety Research
• Clinical Pharmacy Practice

Background:

• Medication errors (MEs) are frequently under-reported by healthcare professionals (HCPs) due to fear and guilt, negatively impacting patient safety.
• A voluntary, anonymous reporting system is crucial for understanding and mitigating MEs.

Purpose of the Study:

• To implement and evaluate a voluntary, anonymous medication error reporting and monitoring program.
• To identify the incidence, aetiologies, and root causes of medication errors in a tertiary care hospital.

Main Methods:

• A prospective observational study conducted over three years in a South Indian tertiary care teaching hospital.
• Implementation of a voluntary, anonymous, stand-alone medication error reporting system.
• Analysis of reported errors, including aetiologies and implicated medication classes, with feedback to HCPs.

Main Results:

• A total of 1310 medication errors were reported among 20,256 hospitalised patients, with an incidence of 6.4%.
• Administration errors (38.2%) were most common, followed by prescribing and transcribing errors (28%).
• Distractions, workload, and communication issues were identified as root causes; analgesics/antipyretics and antibiotics were frequently implicated.

Conclusions:

• A non-punitive, anonymous medication error reporting system initiated by clinical pharmacists can enhance patient safety.
• Understanding error patterns and root causes is essential for developing targeted interventions.
• Promoting a culture of open reporting is vital for continuous improvement in medication safety.