A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan

Khurshid Khowaja¹, Rozmin Nizar¹, Rashida J Merchant², Jacqueline Dias³, Irma Bustamante-Gavino⁴, Amina Malik¹

¹Division of Nursing Services, ²Nursing Education Services, ³Diploma Programme, Nurudin Jivraj Professorship of Nursing, Aga Khan University, Karachi, Pakistan; ⁴The Ahmed Shivji Professorship of Nursing, The Aga Khan University School of Nursing, Karachi, Pakistan

Introduction: Administering medication is one of the high risk areas for any health professional. It is a multidisciplinary process, which begins with the doctor’s prescription, followed by review and provision by a pharmacist, and ends with preparation and administration by a nurse. Several studies have highlighted a high medication incident rate at several healthcare institutions.

Methods: Our study design was exploratory and evaluative and used methodological triangulation. Sample size was of two types. First, a convenient sample of 1000 medication dosages to estimate the medication error (95% CI). We took another sample from subjects involved in medication usage processes such as physicians, nurses, pharmacists, and patients. Two sets of instruments were designed via extensive literature review: a medication tracking error form and a focus group interview questionnaire.

Results: Our study findings revealed 100% compliance with a computerized physician order entry (CPOE) system by physicians, nurses, and pharmacists. The main error rate was 5.5% and pharmacists contributed an higher error rate of 2.6% followed by nurses (1.1%) and physicians (1%). Major areas for improvement in error rates were identified: delay in medication delivery, lab results reviewed electronically before prescription, dispension, and administration.

Keywords: medication error rate, associate error rate, physician, nurse, pharmacist