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Research ArticleIncidence of Medication Errors in a Tertiary CareHospital in South-IndiaGanpisetti Ramesh*, Kanneganti Sundeep, Challa Anitha, Sravya Malika, K Rani Samyuktha,SK Sharmila, P Srinivasa Babu,Department of Pharmacy Practice, Vignan Pharmacy College, Vadlamudi, Guntur, Andhra Pradesh, INDIA.ABSTRACTAim and Objectives: 1) To assess incidence of medication errors. 2) To evaluate percentage of patients admittedwith adverse drug reaction. 3) To evaluate percentage of Error Prone Abbreviations. 4) To analyze the adversedrug event in Patients Receiving High Risk Medication. Methods and Search Strategy: A systematic review ofliterature related to Medication errors in prescribing, transcribing, dispensing, administration and documentationin various subjects, error prone abbreviations, adverse drug events in patients receiving high risk medication werecollected. The following electronic databases were searched: Embase, Pubmed, EBSCO, Allied Health Literature.Results: We reviewed 20796 medication orders and found 1710 medication errors (8.5%), 214 Error ProneAbbreviation (1.1%), 5 patients admitted with Adverse drug reaction (0.45%), 3 adverse drug events in PatientsReceiving High Risk Medication (0.27%). Among the 1710 medication errors (8.5%) – 619 transcribing errors(3.29%), 397 prescribing errors (2.11%), 13 dispensing errors (0.06%), 357 documentation errors (1.89%),214 EPA (1.14%), 5 near miss errors (0.02%), 55 missed dose errors (0.29%) were found. Conclusion: Now adays medication errors are being observed most commonly in a tertiary care hospital. Of the observed medicationerrors transcribing errors were observed more commonly followed by to prescribing, documentation, EPA,dispensing, missed dose errors and near miss errors. We can overcome these medication errors by educatingphysicians, nurses regarding the areas where medication errors are more prone to occur.Key words: Medication error, Prescribing error, Dispensing error, Administration error, Documentation error,Transcribing error, EPA (Electronic prior authorization), Near miss, Missed dose.INTRODUCTIONDrug use is a complex process and thereare many drug related challenges at variouslevels. Medication misadventure can occuranywhere in the health care system andpharmacists have an active role in monitoringthe appropriate use of drugs.1 Medicationerrors are a common cause for iatrogenicadverse events and are reported to be theseventh most common cause of deathoverall. They can lead to severe morbidity,prolonged hospitals stay, unnecessarydiagnostic tests, unnecessary treatments anddeath.2,3Medication errors often occur when cliniciansare inexperienced and new procedures areintroduced. Extremes of age, complexcare, urgent care and prolonged hospitalstay are associated with more errors (Table1). This hospital medication use process92 can be categorized into five broad stages:prescription, transcription, preparation,dispensation and administration. An errorcan occur at any point in this process.Medication errors mainly occur during theadministration stage (median of 53% ofall errors), followed by prescription (17%),preparation (14%) and transcription (11%)(Table 2). Occurrence of an error that didnot result in harm is called near miss error.4,5The use of inappropriate abbreviations inprescriptions may alter intended therapeuticoutcomes and even cause unnecessaryharm to patients.6 Despite these warnings,error prone abbreviations continue to beused.7 The rapid development of electronicprescriptions have minimized this problemto an extent, but hand-written prescriptionswill continue to be used, especially inDOI: 10.5530/ijopp.12.2.21Address forcorrespondence:Ramesh Ganpisetti,Department of Pharmacy Practice, Vignan Pharmacy College,Vadlamudi, Guntur-522213,Andhra Pradesh, INDIA.Phone no: 91 8686473659Email Id: ramiganpisetti@gmail.comwww.ijopp.orgIndian Journal of Pharmacy Practice, Vol 12, Issue 2, Apr-Jun, 2019

Ganpisetti, et al.: Incidence of Medication and ErrorsTable 1: Incidence of medication error.MONTHJan 1410148015601850195023002600230121001600Total Errors460272141114879713111513710155Inpatient 6.3618.789.197.084.504.675.294.245.834.543.48Out of 20796 medication orders we found 1710 medication errors (8.5%) in span of 11 months, of which highest incidence of medication errors were observed in January andlowest incidence medication errors were observed in November.Table 2: Incidence of types of medication errors.Types of errorsJan 4193569EPA962214127315171486Near miss00002110101Missed dose0060610318651Among 1710 medication errors (8.5%) – 619 transcribing errors (3.29%), 397 prescribing errors (2.11%), 13 dispensing errors (0.06%), 357 documentation errors (1.89%),214 EPA (1.14%), 5 near miss errors (0.02%), 55 missed dose errors (0.29%) were founddeveloping countries. Therefore, eliminating error-proneabbreviations and standardizing acceptable abbreviationsis an urgent need.8Adverse drug events (ADEs) and their associatedmorbidity and mortality represent a significant burden onthe healthcare system.9 Medication error (miscalculations,misadministration, difficulty in interpreting handwrittenorders, misunderstanding of verbal orders etc) and ADRtogether known as ADE. Systemic reviews have estimatedthat approximately 5–10% of total hospital admissionsare related to an ADE(Table 3).Adverse Drug Reactions (ADRs) - unintended, harmfulevents attributed to the use of medicines - occur as a causeof and during a significant proportion of unscheduledhospital admissions.10 A careful medication historycan assist a prescriber in understanding the patient’sprevious experiences with drug treatment, particularly inidentifying previous ADRs that may preclude re-exposureto the drug (Table 4).6Table 3: Percentage of admissions with adverse drugreactions.MONTHADR%Jan MarAprilMaySepWe reviewed 20796 medication orders of which 5 patients were admitted withadverse drug reaction (0.45%), in a span of 11 months. Highest percentage ofadverse drug reactions were observed in November and there were no adversedrug reactions in January, February, March, April, May, August and September.RESULTSWe reviewed 20796 medication orders and found1710 medication errors (8.5%), 214 Error ProneAbbreviation (1.1%) (Table 5), 5 patients admittedwith Adverse drug reaction (0.45%), 3 adverse drugevents in Patients Receiving High Risk Medication(0.27%). Among the 1710 medication errors (8.5%)– 619 transcribing errors (3.29%) (Figure 1-3) 397Indian Journal of Pharmacy Practice, Vol 12, Issue 2, Apr-Jun, 2019 Figure 1: Graph representing incidence of medication errors.93

Ganpisetti, et al.: Incidence of Medication and ErrorsTable 4: Percentage of error prone ugSepOctNovSample 15%0.65%0.6%0.60%0.38%0.36%We reviewed 20796 medication orders and we found 214 Error Prone Abbreviation (1.1%) in a span of 11 months of which we found highest percentage of medication errorprone abbreviations in January and lowest percentage of medication error prone abbreviations in November.Table 5: Percentage of patients receiving high risk medications developing adverse drug events.MONTHADVERSE EVENT (ADE ADR)%Jan 0.18%Sep10.20%Oct00Nov00We reviewed 20796 medication orders of which 3 adverse drug events in Patients Receiving High Risk medication (0.27%) were observed in a spanof 11 months.Figure 2: Graph representing % of admissions with adverse drugreactions.prescribing errors (2.11%), 13 dispensing errors (0.06%),357 documentation errors (1.89%), 214 EPA (1.14%),5 near miss errors (0.02%), 55 missed dose errors (0.29%)were found (Figure 4,5).CONCLUSIONNow a day’s medication errors are being observedmost commonly in a tertiary care hospital. Most ofthose errors are the results of problems created bytoday’s complex health care system. Of the observedmedication errors transcribing errors were observed more94 Figure 3: Graph representing % of error prone abbreviations.commonly followed by to prescribing, documentation,dispensing, missed dose errors and near miss errors.We can overcome these medication errors by educatingphysicians, nurses regarding the areas where medicationerrors are more prone to occur. Computerized physicianorder entry, automated dispensing, bar code medicationadministration, medication reconciliation and personnelhealth records are vital components to prevent medicationerrors now a days (Table 6,7).Suggested RecommendationAccording to the review results, the followingIndian Journal of Pharmacy Practice, Vol 12, Issue 2, Apr-Jun, 2019

Ganpisetti, et al.: Incidence of Medication and ErrorsTable 7: Compliance rate to outpatient medicationprescription in capitals.Table 6: Compliance rate to inpatient medicationprescription in capitals.MonthTotal prescriptionsobserved in OPIn capital%May nsobserved in IPIn capital%May 2016250225June270JulyWe reviewed 9552 inpatient prescriptions of which 9233 prescriptions were writtenin capitals (96.66%) in a span of 7 months. More no. of prescriptions were written incapitals during April, lowest were observed in January.We reviewed 1340 outpatient prescriptions of which 791 prescriptions were writtenin capitals (59.02%) in a span of 7 months. More no. of prescriptions were written incapitals during March, lowest were observed in January and February. Improve medication error reporting systemsand policy among organizations by removingbarriers, clarifying the importance of reporting andencouraging healthcare professionals.Carryout regular intensive educational and trainingprograms in pharmacotherapy for undergraduatemedical and para medical students.Educational programs by clinical pharmacies andclinical pharmacologists in drug therapy are urgentlyneeded for doctors and nurses.Figure 4: Graph representing compliance rate to outpatient medicationprescription in capitals.ACKNOWLEDGEMENTWe are thankful to Ramesh Hospital for providingnecessary facilities and support. We are also thankful to allthe Departments of Ramesh Hospital for their immensesupport. All authors would like to thank Ramesh Hospitalfor their constant support and encouragement.CONFLICT OF INTERESTNo conflict of interest.Figure 5: Compliance rate to inpatient medication prescription incapitals.ABBREVIATIONSrecommendations are suggested to allow decision makersto improve medication safety and reduce medicationerrors:EPA: Electronic prior authorization; ADR: Adversedrug reactions; ADE: Adverse drug event. Increase the awareness of medication errors ofhealthcare professionals.SUMMARY Prescribers need to pay more attention to drugdosing.We can overcome these medication errors by educatingphysicians, nurses regarding the areas where medicationerrors are more prone to occur. Computerized physicianIndian Journal of Pharmacy Practice, Vol 12, Issue 2, Apr-Jun, 2019 95

Ganpisetti, et al.: Incidence of Medication and Errorsorder entry, automated dispensing, bar code medicationadministration, medication reconciliation and personnelhealth records are vital components to prevent medicationerrors now a days.4. Eschenbach ACV. Eliminating error-prone notations in medical communications.Expert Opin Drug Saf. 2007;6(3):233-4.5. Benjamin DM. Reducing medication errors and increasing patient safety: Casestudies in clinical pharmacology. J Clin Pharmacol. 2003;43(7):768-83.6. Jamie JC, Sarah KP. Adverse drug reactions. Clinical Medicine. 2016;16(5):481-5.7. Dooley MJ, Wiseman M, Gu G. Prevalence of error-prone abbreviations used inmedication prescribing for hospitalized patients: Multi-hospital evaluation. InternREFERENCES1. Krahenbuhl-Melcher A, Schlienger R, Lampert M, Haschke M, Drewe J,Krahenbuhl S. Drug-related problems in hospitals: Areview of the recentliterature. Drug Safety. 2007;30(5):379-407.2. Harten WHV, Manen JV. The Occurrence of Medication Errors and theOccurrence of Risk Factors for Medication Errors in State Hospitals in Ghana:Patient’s Safety Improvement in Focus. Healthcare Management. 2009;1-74.3. Buck ML, Hofer KN, McCarthy MW. Medication rates in Infants and Children,Improving Pediatric Medication Safety Part 1. Paediatr Pharm. 2008;14:1-5.96 Med J. 2012;42(3):e19-22.8. Miasso AI, Oliveira RCD, Silva AEBDC, et al. Prescription errors inBrazilian hospitals: A multi-centre exploratory survey. Cad Saude Publica.2009;25(2):313-20.9. tingandPrevention (NCC MERP): About Medication Errors. http://www.nccmerp.org/medErrorCatIndex.html.10. Nebeker JR, Barach P, Samore MH. Clarifying adverse drug events: Aclinician’s guide to terminology, documentation and reporting. Ann Intern Med.2004;140(10):795-801.Indian Journal of Pharmacy Practice, Vol 12, Issue 2, Apr-Jun, 2019

We can overcome these medication errors by educating physicians, nurses regarding the areas where medication errors are more prone to occur. Key words: Medication error, Prescribing error, Dispensing error, Administration error, Documentation error, Transcribing error, EPA (Electronic prior authorization), Near miss, Missed dose. INTRODUCTION

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