Zahraa Hassan Abdelrahman Shehata1, Nagwa Ali Sabri2, Ahmed Abdelsalam Elmelegy3. 1. Hospital pharmacy department, Egyptian drug authority, ministry of health, Egypt. Zahraahassan1988@gmail.com. 2. Head of Clinical Pharmacy Department, Faculty of Pharmacy - Ain Shams University, Cairo, Egypt. 3. Professor of Pharmacology, Faculty of Medicine - Ain Shams University, Cairo, Egypt.
Abstract
OBJECTIVES: This study analyzes reports to the Egyptian medication error (ME) reporting system from June to December 2014. METHODS: Fifty hospital pharmacists received training on ME reporting using the national reporting system. All received reports were reviewed and analyzed. The pieces of data analyzed were patient age, gender, clinical setting, stage, type, medication(s), outcome, cause(s), and recommendation(s). RESULTS: Over the course of 6 months, 12,000 valid reports were gathered and included in this analysis. The majority (66%) came from inpatient settings, while 23% came from intensive care units, and 11% came from outpatient departments. Prescribing errors were the most common type of MEs (54%), followed by monitoring (25%) and administration errors (16%). The most frequent error was incorrect dose (20%) followed by drug interactions, incorrect drug, and incorrect frequency. Most reports were potential (25%), prevented (11%), or harmless (51%) errors; only 13% of reported errors lead to patient harm. The top three medication classes involved in reported MEs were antibiotics, drugs acting on the central nervous system, and drugs acting on the cardiovascular system. Causes of MEs were mostly lack of knowledge, environmental factors, lack of drug information sources, and incomplete prescribing. Recommendations for addressing MEs were mainly staff training, local ME reporting, and improving work environment. DISCUSSION: There are common problems among different healthcare systems, so that sharing experiences on the national level is essential to enable learning from MEs. Internationally, there is a great need for standardizing ME terminology, to facilitate knowledge transfer. Underreporting, inaccurate reporting, and a lack of reporter diversity are some limitations of this study. Egypt now has a national database of MEs that allows researchers and decision makers to assess the problem, identify its root causes, and develop preventive strategies.
OBJECTIVES: This study analyzes reports to the Egyptian medication error (ME) reporting system from June to December 2014. METHODS: Fifty hospital pharmacists received training on ME reporting using the national reporting system. All received reports were reviewed and analyzed. The pieces of data analyzed were patient age, gender, clinical setting, stage, type, medication(s), outcome, cause(s), and recommendation(s). RESULTS: Over the course of 6 months, 12,000 valid reports were gathered and included in this analysis. The majority (66%) came from inpatient settings, while 23% came from intensive care units, and 11% came from outpatient departments. Prescribing errors were the most common type of MEs (54%), followed by monitoring (25%) and administration errors (16%). The most frequent error was incorrect dose (20%) followed by drug interactions, incorrect drug, and incorrect frequency. Most reports were potential (25%), prevented (11%), or harmless (51%) errors; only 13% of reported errors lead to patient harm. The top three medication classes involved in reported MEs were antibiotics, drugs acting on the central nervous system, and drugs acting on the cardiovascular system. Causes of MEs were mostly lack of knowledge, environmental factors, lack of drug information sources, and incomplete prescribing. Recommendations for addressing MEs were mainly staff training, local ME reporting, and improving work environment. DISCUSSION: There are common problems among different healthcare systems, so that sharing experiences on the national level is essential to enable learning from MEs. Internationally, there is a great need for standardizing ME terminology, to facilitate knowledge transfer. Underreporting, inaccurate reporting, and a lack of reporter diversity are some limitations of this study. Egypt now has a national database of MEs that allows researchers and decision makers to assess the problem, identify its root causes, and develop preventive strategies.
Keywords:
Egyptian Drug Authority (EDA); National Office for Handling and Reduction of Medication Errors (NO HARMe); incident reporting; medication errors; patient safety
Authors: Maryam Ali Alharaibi; Abdullah A Alhifany; Yousif A Asiri; Monira M Alwhaibi; Sheraz Ali; Parameaswari P Jaganathan; Tariq M Alhawassi Journal: Ann Saudi Med Date: 2021-06-01 Impact factor: 1.526