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Published on: September 20, 2018
A retrospective study on prevalence, characteristics, and outcomes of transcribing error: analysis of data from the
Norazida Ab Rahman1, Ee Vien Low2, Fateha Kamaruddin3
1Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Malaysia.
Background:
Medication errors (MEs) represent avoidable harm that occurs within the healthcare system. While most MEs do not pose significant safety threats, some can result in severe harm, disability, or even death for patients. We aimed to describe the prevalence, characteristics, and outcomes of MEs due to transcribing errors.
Methods:
Retrospective analysis of data from the Medication Error Reporting System (MERS) in Malaysia. All ME reports submitted to MERS were verified and classified by trained pharmacists from the Ministry of Health Malaysia. Transcribing errors were identified from all ME reports submitted to MERS that were classified as 'data entry error'. All data from public health facilities (hospitals and clinics) submitted in 2018-2022 were included in the analysis. Descriptive analyses were conducted on frequencies and characteristics of the transcribing errors.
Results:
From January 2018 to December 2022, 265,194 MEs were reported to the MERS, of which 12,049 (4.5%) were transcribing errors. The large proportion of transcribing error was related to dose error, i.e. incorrect dose (48.6%) and incorrect frequency (19.9%), followed by drug error (incorrect drug, 13.3% and incorrect patient, 6.3%). The majority of the errors do not reach patients (94.8%). The most possible error causes and contributing factors were work and environment followed by staff factors, task and technology, and medication-related.
Conclusion:
There was an increase in voluntary reporting over the years, reflecting a growing culture of reporting among healthcare professionals. These findings offer valuable insights into medication errors caused by transcribing processes in Malaysia, which can inform efforts to improve pharmacy practices, design appropriate interventions, and reduce harm to patients.
Insights
Medication errors from transcribing are a significant issue, with dose and drug errors being most common. While most errors don't reach patients, understanding causes can improve safety.
Area of Science:
- Healthcare Safety
- Pharmaceutical Sciences
- Clinical Pharmacy
Background:
- Medication errors (MEs) are preventable adverse events in healthcare.
- Some MEs can lead to severe patient harm, disability, or death.
- Transcribing errors are a specific type of ME with significant implications.
Purpose of the Study:
- To determine the prevalence of medication errors stemming from transcribing.
- To characterize the types and outcomes of these transcribing errors.
- To identify contributing factors for transcribing errors in a healthcare system.
Main Methods:
- Retrospective analysis of the Medication Error Reporting System (MERS) in Malaysia.
- Inclusion of all ME reports classified as 'data entry error' from public health facilities (2018-2022).
- Descriptive analysis of error frequencies, characteristics, and contributing factors.
Main Results:
- 4.5% of 265,194 MEs were transcribing errors (12,049 cases).
- Dose errors (incorrect dose/frequency) constituted the majority (68.5%), followed by drug errors (13.3%).
- Most errors (94.8%) did not reach patients; work/environment factors were primary causes.
Conclusions:
- Increased reporting suggests a growing safety culture.
- Findings provide insights into transcribing errors in Malaysian pharmacy practice.
- Results can guide interventions to reduce patient harm from medication transcription errors.
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