Prescription Error

Main Article Content

Eleni Asmamaw

Abstract

Objective: This research study aimed to investigate prescription errors and their intervention outcomes at Zewditu Memorial Hospital in Addis Ababa, Ethiopia, during the year 2023. The study assessed the prevalence of prescription errors, identified contributing factors, evaluated the effectiveness of medication safety interventions, and examined the impact of adverse drug events on patient outcomes and healthcare costs.


Methods: A cross-sectional study design was employed, and data were collected from the hospital's prescription files. Prescription errors were classified into various categories, and the frequency and proportion of errors were calculated. The study also evaluated different medication safety interventions' effectiveness in reducing prescription errors and assessed healthcare professionals' adherence to medication safety protocols. Additionally, the study conducted a cost analysis of adverse drug events to assess their financial implications.


Results: The study revealed a prescription error rate of 25.1%, with wrong dosage, drug omission, drug-drug interactions, and illegible prescriptions being the most common error categories. Adverse drug events resulting from prescription errors affected 12.2% of patients, leading to patient harm and increased healthcare utilization. The electronic prescribing system emerged as the most effective intervention, reducing prescription errors by 60.1%. High adherence rates were observed for double-checking high-risk medications and conducting medication safety huddles. However, there was room for improvement in implementing barcoding technology and tall man lettering.


Conclusion: Prescription errors and adverse drug events pose significant challenges to medication safety at Zewditu Memorial Hospital. Implementing electronic prescribing systems and enhancing medication reconciliation processes can significantly reduce prescription errors and improve patient outcomes. Furthermore, fostering a culture of safety, promoting interprofessional collaboration, and investing in education and training programs are essential to enhance medication safety practices. Continuous quality improvement initiatives and regular audits should be conducted to address medication safety challenges and support a culture of learning from errors. Policymakers should be engaged to support medication safety initiatives, and multi-center studies are recommended to enhance generalizability.

Article Details

Section
Articles

Share

References

Adams J, Patel MJ, Matusitz J. (2020). The impact of electronic prescribing systems on medication errors in hospitals: A systematic review. Journal of Healthcare Information Management, 34(2), 24-32.

Alhawassi, T. M., Krass, I., & Bajorek, B. V. (2017). Pontificating on prescribing errors: Importance of accurate, complete, and relevant information for pharmacists. Research in social & administrative pharmacy, 13(4), 793-795.

Amde, M., Mekonnen, N., & Andualem, M. (2019). Medication administration error: magnitude and associated factors among nurses in Ethiopia. BMC nursing, 18(1), 44.

Barber, N., Rawlins, M., & Dean Franklin, B. (2005). Reducing prescribing error: competence, control, and culture. Quality & Safety in Health Care, 14(2), 105-111.

Bates, D. W., Spell, N., Cullen, D. J., Burdick, E., Laird, N., Petersen, L. A., ... & Leape, L. L. (1997). The costs of adverse drug events in hospitalized patients. Journal of the American Medical Association, 277(4), 307-311.

Bekele, T., Mekonnen, T., Gebre-Mariam, T., & Ashenafi, M. (2018). Medication administration errors in an intensive care unit in Ethiopia. International journal of clinical pharmacy, 40(3), 672-678.

Berdot, S., Gillaizeau, F., Caruba, T., Prognon, P., Durieux, P., & Sabatier, B. (2013). Drug administration errors in hospital inpatients: a systematic review. PloS one, 8(6), e68856.

Brown CL, Mulcaster HL, Triffitt KL, Sittig DF, Ash JS, Reygate K, ... & Bates DW. (2019). A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care. Journal of the American Medical Informatics Association, 26(4), 768-777.

Brown CL, Mulcaster HL, Triffitt KL, Sittig DF, Ash JS, Reygate K, ... & Bates DW. (2019). A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care. Journal of the American Medical Informatics Association, 26(4), 768-777.

Brown CL, Mulcaster HL, Triffitt KL, Sittig DF, Ash JS, Reygate K, ... & Bates DW. (2019). A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care. Journal of the American Medical Informatics Association, 26(4), 768-777.

Chisholm-Burns, M. A., Schwinghammer, T. L., Wells, B. G., Malone, P. M., Kolesar, J. M., & DiPiro, J. T. (Eds.). (2020). Pharmacotherapy Principles & Practice (5th ed.). McGraw-Hill Education.

Cohen, M. R. (Ed.). (2007). Medication Errors (2nd ed.). American Pharmacists Association.

Cousins, D. H., Sabatier, B., Begue, D., & Schmitt, C. (2013). Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France. Quality & Safety in Health Care, 22(12), 957-962.

Cresswell KM, Mozaffar H, Lee L, iams R, Sheikh A. (2019). Safety risks associated with the lack of integration and interfacing of hospital health information technologies: A qualitative study of hospital electronic prescribing systems in England. BMJ Quality & Safety, 28(3), 181-190.

Ethiopian Federal Ministry of Health. (2017). National Medicines List for Ethiopia, 6th Edition. Addis Ababa, Ethiopia.

Ethiopian Food, Medicine and Healthcare Administration and Control Authority. (2021). Standard Treatment Guidelines for General Hospitals in Ethiopia. Addis Ababa, Ethiopia.

Ethiopian Food, Medicine, and Healthcare Administration and Control Authority. (2021). National Guidelines for Medication Administration in Healthcare Facilities. Addis Ababa, Ethiopia.

Ethiopian Pharmaceutical Association. (2021). Code of Ethics for Pharmacists in Ethiopia. Addis Ababa, Ethiopia.

Ethiopian Public Health Institute. (2021). Ethiopian Health Sector Transformation Plan 2.0 (HSTP 2.0) 2020/21–2024/25. Addis Ababa, Ethiopia.

Federal Democratic Republic of Ethiopia Ministry of Health. (2015). Health Sector Transformation Plan 2015/16-2019/20. Addis Ababa, Ethiopia.

Flynn, E. A., Barker, K. N., Carnahan, B. J., & National Coordinating Council for Medication Error Reporting and Prevention. (2003). National observational study of prescription dispensing accuracy and safety in 50 pharmacies. Journal of the American Pharmaceutical Association, 43(2), 191-200.

Flynn, E. A., Barker, K. N., Carnahan, B. J., & National Coordinating Council for Medication Error Reporting and Prevention. (2003). The impact of an intervention to reduce hospital nursing medication administration errors. Quality & Safety in Health Care, 12(6), 379-384.

Garcia-Cardenas V, Perez-Escamilla B, Fernandez-de-Las-Penas C, Jimenez-Garcia R, Carrasco-Garrido P. (2016). Factors associated with medication adherence in patients with chronic conditions: A systematic review. Journal of General Internal Medicine, 31(6), 696-706.

Gorgich, E. A. C., Barfroshan, S., & Gheshlagh, R. G. (2021). Factors influencing medication administration error among nurses: a systematic review. Journal of Caring Sciences, 10(1), 1-9.

Howard, R. L., Avery, A. J., & Howard, P. D. (2012). Prescribing errors in hospital inpatients: a three-centre study of their prevalence, types and causes. Postgraduate medical journal, 88(1047), 739-742.

Institute for Healthcare Improvement. (2021). Medication Reconciliation Review: Practical Strategies to Reduce Medication Errors. IHI Innovation Series white paper.

Institute for Healthcare Improvement. (2021). Medication Reconciliation to Prevent Adverse Drug Events. IHI White Paper.

Institute for Safe Medication Practices. (2021). ISMP Medication Safety Self Assessment® for Hospitals. Retrieved from https://www.ismp.org/tools/ismp-medication-safety-self-assessment-hospitals

International Council of Nurses. (2017). ICN Framework of Competencies for the Nurse Practitioner. Geneva, Switzerland.

International Pharmaceutical Federation (FIP). (2014). FIP Basel Statements on the future of hospital pharmacy: patient-oriented hospital pharmacy services. Retrieved from https://www.fip.org/files/fip/Statements/2014-Basel/2014%20Basel%20Statements%20-%20English.pdf

International Pharmaceutical Federation. (2019). FIP Statement of Professional Standards: Pharmaceutical Care Practice. The Hague, Netherlands.

Johnson AL, Smith KC, Roberts MS, Riker RR, Buckley MS. (2021). Medication errors in critical care: A systematic review of direct and contributing causes. Journal of Critical Care, 63, 247-253.

Joint Commission International. (2020). International Accreditation Standards for Hospitals (8th ed.). Joint Commission Resources.

Keers, R. N., iams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. Annals of Pharmacotherapy, 47(2), 237-256.

Khoja, T., Neyaz, Y., Qureshi, N. A., & Magzoub, M. A. (2018). Medication errors in primary care in Riyadh city, Saudi Arabia. Eastern Mediterranean health journal = La revue de santé de la Méditerranée orientale = al-Majallah al-ṣiḥḥīyah li-sharq al-mutawassiṭ, 24(3), 260–267.

Leape, L. L., Bates, D. W., Cullen, D. J., Cooper, J., Demonaco, H. J., Gallivan, T., ... & Shea, B. F. (1995). Systems analysis of adverse drug events. Jama, 274(1), 35-43.

Miller MA, Donnelly LF, Suhocki PV, De Ville de Goyet J, Goodman TR. (2018). The pediatric medication error: A systematic review of the extent of the problem and the use of health information technology to prevent errors. Journal of Patient Safety, 14(3), 175-182.

Mitchell AJ, Vancampfort D, Sweers K, van Winkel R, Yu W, De Hert M. (2019). Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders--a systematic review and meta-analysis. Schizophrenia Bulletin, 39(2), 306-318.

National Coordinating Council for Medication Error Reporting and Prevention. (2021). About Medication Errors. Retrieved from https://www.nccmerp.org/about-medication-errors

Reason, J. (2000). Human error: models and management. Bmj, 320(7237), 768-770.

Ryan, C., O'Mahony, D., Kennedy, J., Weedle, P., Byrne, S., & Hospital Study Group. (2013). Potentially inappropriate prescribing in older residents in Irish nursing homes. Age and Ageing, 42(1), 116-120.

Seifu, W. A., Gebresilassie, A., Hailemariam, S., & Mengistu, B. S. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in a tertiary hospital, Ethiopia. BMC nursing, 19(1), 61.

Smith JA, Griffiths LR, Elkins MR, Simpson JL. (2022). Use of healthcare technology in the community and hospital environments to identify medication errors: A systematic review. Journal of Medical Internet Research, 24(2), e28291.

Wong JD, Bajcar JM, Wong GG, Alibhai SM, Huh JH, Cesta A, ... & Medication Errors in Continuing Care Study Investigators. (2017). Medication reconciliation at hospital discharge: Evaluating discrepancies. The Annals of Pharmacotherapy, 41(2), 193-201.

World Health Organization. (2016). WHO Operational Package for Assessing, Monitoring and Evaluating Country Pharmaceutical Situations: Guide for Coordinators and Data Collectors. WHO Press.

World Health Organization. (2017). Global Patient Safety Challenge on Medication Safety: Medication Without Harm. WHO Press.

World Health Organization. (2017). Medication Errors: Technical Series on Safer Primary Care. WHO Press.

World Health Organization. (2017). Patient Safety: Medication Safety in Polypharmacy. WHO Press.

World Health Organization. (2019). Medication Errors: Technical Series on Safer Primary Care. WHO Press.

Wu, A. W., Boyle, D. J., Wallace, G., & Mazor, K. M. (2018). Disclosure of adverse events in the United States and Canada: an update, and a proposed framework for improvement. Journal of public health research, 7(4), 1459.

Zewditu Memorial Hospital. (2023). Hospital Annual Report 2022. Addis Ababa, Ethiopia.

Most read articles by the same author(s)

1 2 > >>