Analysis of Reported E-prescribing Medication Administration Errors at King Saud Medical City, Riyadh: A Cross-Sectional, Retrospective Study

ABSTRACT

Background:Drugprescriptionerrorisamedicationerrorthatmostfrequentlyhappensinhealthcareorganizationsandadverselyaffectsthehealthcareconsumers.Mostmedicationerrors(MEs)butnotallarecapturedandcorrectedbeforereachingthepatientbydesignedsystemcontrols.Medicationadministrationerrors(MAEs)mostlyaremadebynursesbutfrequentlyreportedbyclinicalpharmacistsinhospitalsinSaudiArabia.Objective:ThisstudyaimedtoanalyzeexclusivelythevoluntarilyreporteddrugadministrationerrorsinatertiarycarehospitalinRiyadhcity.Methods:Thiscross-sectional,retrospectivestudyevaluatedconsecutivelycollectedmedicationadministrationreportformsoveraperiodofoneyearfromJanuary1,2015toDecember31,2015.Results:ThenumberofMAEsoccurringduringstageofdrugadministrationconstituted7.1%(n=971)oftotalmedicationerrors(n=13677).ThemaximumnumberofMEs(n=6838,50%)and MAEs(n=455,46.9%)occurredduringthe4thquarteroftheyear2015.ThemostcommonMAEhappenedtobecategoryC(n=888,91.5%)whichmeanserroroccurred,reachedthepatientbutwithoutcausinganyharm.ConcerningMAEtypes,themostcommonerrorincludedwrongfrequency(40%)followedbywrongdrug(17%),wrongtimeofadministration(16%)andwrongrateofinfusion(10%).Nursesmadethemostoftheerrors(92.2%)whiletheclinicalpharmacistsreportedthemostMAEs(75.5%).Highalertmedications(HAM)errorsconstituted32.3%(n=314)ofMAEs(n=971)andmostcommonHAMerrorsincludedthewrongrouteofadministrationofLanusInsulin(15%)followedbyInsulinAspart(15%),Enoxaparin(13%)andInsulinProtamine-Nvomix(12%).Look-alikeandsound-alike(LASA)errorsconstituted55.2%ofMAEs(971/536)andmostcommonLASAdrugsidentifiedwereGentamycin(13%),InsulinMixtard(11%),NPHInsulin(8%)Intralipidvial(8%)andInsulinregular(6%).Conclusion:ThisretrospectivestudyprovidessomeimportanttentativepharmacovigilanceinsightsintoMAEs,whicharepartiallycomparablewithcurrentinternationaltrendsindrugadministrationerrors.FurtherstudiesonMAEsarewarrantednotonlyintheKingdomofSaudiArabiabutalsootherGulfcountries