THE PREVALENCE, CAUSES, AND CONSEQUENCES OF MEDICATION ERRORS IN A TERTIARY HOSPITAL: A RETROSPECTIVE REVIEW AND INSIGHTS FROM HEALTH CARE PROFESSIONALS

Abstract

Background: Inpatient medication errors pose a substantial risk to patient safety particularly in critical units of tertiary hospitals like the ICU and Emergency Department. These errors lead to adverse drug events (ADEs), prolonged hospitalization, and additional patient suffering. The objective of this study has been to evaluate the scope of medication error practices within a tertiary care hospital, outlining their potential causes and consequences alongside possible solutions aimed towards mitigating their prevalence.

Methods: A retrospective observational study was done at a 750 built bed tertiary hospital over the period of 12 months (January–December 2023). Records from electronic health records (EHR), incident logs, and the pharmacies’ records were analyzed. Error rates, types, and severity levels underwent quantitative analysis, while qualitative analysis sought the experiences of the providers through interviews which were subjected to thematic analysis.

Results: ICU (12.5%) and Emergency Department (8.0%) showed the highest rates of medication errors. Out of the 5800 cases reviewed, Prescribing errors (42.5%) and administration errors (37.7%) were the most common types. Cumulatively, 35% of the errors led to moderate to severe harm and 2.4% resulted in death. The most dangerous drug classes were: antibiotics (21.2%), anticoagulants (14.1%), and opioids (12.9%). Qualitative analysis pointed out failure to communicate, heavy workloads, and insufficient training as factors that led to errors.

Conclusion: The problem of medication errors persist at tertiary hospitals, especially those located in high-risk units. Addressing limitations in workload, improving documentation practices, implementing CPOE, and developing a culture that encourages non-punitive reporting of mistakes can reduce errors and improve patient safety.