Assessment of Medication Errors of Drugs in Emergency Department of a Tertiary Care Teaching Hospital

Shiv Kumar¹*, Santanu Mal², Alfred Manoj³

¹Professor and Head of the Department, Department of Pharmacy Practice,

N.E.T. Pharmacy College, Raichur - 584103 Karnataka, India.

²Department of Pharmacy Practice, N.E.T. Pharmacy College, Raichur, Karnataka, India.

³Department of Pharmacy Practice, N.E.T. Pharmacy College, Raichur, Karnataka, India.

*Corresponding Author E-mail: shivkumarmatur@gmail.com, santanu.mal02051998@gmail.com, alfredmanoj28@gmail.com

ABSTRACT:

Background: Medication errors (MEs) are common in Indian hospitals which can cause significant harm to the patients. The emergency unit is a high-risk environment for irrational use of medication due to stressors and time sensitive nature of the service. Medication errors may occur at any stage of prescribing, documenting, dispensing, administration. Objective: This study was planned to assess incidence and various types of medication errors of drugs reported in emergency medicine department. Methodology: A prospective observational study was conducted for six months February 2022 to August 2022 in Navodaya medical college, hospital & research centre with a sample size of 220. Data were collected from all hospitalized patients who are admitted in the emergency department in the hospital during the study period. Result: Among the 220 cases collected, 84(38.18%) cases are found medication errors. Total 163 number of drugs were reported as medication error. The majority of MEs was found prescribing error 92(56.44%), followed by administration error 67(41.11%), and 4(2.45%) dispensing error was found. Conclusion: In our study the majority types of errors we found prescription errors followed by administration error. Overlooked drug-drug interactions is the major problem or medication error in our emergency department. We believe that every healthcare professional should be aware of these medication errors and overcome the all types of errors.

KEYWORDS: Emergency department, Prescription errors, Administration errors, Dispensing error, National Coordinating Council for Medication Error Reporting and Prevention.

INTRODUCTION:

Medication errors (MEs) can take place at any step from prescribing to the administration of the drug. In India, 5.2 million injuries have been reported each year due to medication errors and adverse events reported in hospitals per year due to medication error. Medication errors occurs due to lack of knowledge, poor performance and psychological factors.

The pharmacist has an important role along with physicians, nurses, administrators to examine and improve healthcare system in order to confirm the patient safety.¹The steps whereby writing prescription for medications comprising a huge number of people such as patient, nurse, prescriber, pharmacist, or care takers.²

To provide safe practice these persons interact with each other. In general practice the fatal drugs errors known to be more commonly found in hospitals. The focus of studies is the common problem of medication errors.³ In India, the medication errors and drugs related problems are basically due to illogical use of medications.

· Identify the most common errors related to drugs.

· Review some of the critical points at which drugs related errors are most likely to take place.⁴

The large volume of cases and labors to reduce wait times that make high pressures. This is not extraordinary because further than three fourth of emergency department visits are related to administer or prescribing drugs, displaying further than 210 million drugs encounters annually in the United States. Many studies have demonstrated the value of pharmacists’ interventions in the emergency department.⁵

Medication errors have been defined as “failure in the treatment process that possible to harm to the patient.” Medication errors may come at each five stages of medication ordering and delivery including prescription, transcription, dispensing, administration, or monitoring.⁶ Medication errors comes in 2-14% of hospitalized patients and lead to 44,000-98,000 annual deaths in the United State. Emergency departments (EDs) are characterized by simultaneous care of multiple patients with various complex medical conditions most of them are acutely ill.⁷ There are always chances of error in prescribing medicines in emergency care department as the patient is in critical condition and physicians must take quick decisions.⁸ Also, the clinicians come across different patients with varied unexpected conditions in acute and unpredictable state. Irrational prescribing of medicines may tend to produce an unproductive and dangerous treatment to the patients.⁹

MATERIALS AND METHODS:

A prospective observational study was carried out for 6 months in Navodaya Medical College Hospital and Research Centre, Raichur. 220 participants were collected. Data was pooled and analyzed. Ethical permission to conduct the study was granted by the institutional ethics committee.

Study Population:

Data were collected from the case sheets using a specially designed data entry form from patients who are admitted in emergency ward in the hospital during the study period. Participants with both males and females and all age patients are included in the study.

Analysis of data: The data were analysed and monitored for the following variables:

· Patient demographics

· Types of medication errors

· Frequency of medication errors

· Drugs which cause medication errors

· Dosage forms involved in MEs

· NCCMERP categorization

Data was collected and analyzed using Microsoft excel. Descriptive statistics was used and results were presented as tables or expressed as percentages and frequency distribution according to type of information collected.

Ethical consideration:

The ethical approval to conduct the study was obtained from the Ethical Review Committee of Hospital.

RESULTS:

Demographic Data:

A prospective observational study was carried out by collecting data from 220 patients who were admitted in ED during the study period. Out of 220 cases 84 cases were found medication errors. Medication errors were most frequent for patients in the age group of (45 – 64) years and the age group to be least affected was (0 – 14) years. However, 2 patients affected by MEs were children between ages of 8 and 15 years. This is depicted in Table1.

Table 1: age-wise distribution of MEs (n=84)

Age (years)	No. of patients with errors	Percentage (%)
0 - 14	1	1.19
15 - 24	8	9.52
25 - 44	24	28.57
45 - 64	41	48.81
>65	10	11.91

Types and frequency of MEs:

Among the 220 cases collected, 84(38.18%) cases are found medication errors. Total 163 numbers medication errors were reported. The majority of MEs was found prescribing error 92(56.44%), followed by administration error 67(41.11%), and 4(2.45%) dispensing error was found. The most frequently reported type of Prescribing Errors was Missed dose (17.39%) followed by Illegible handwriting (16.31%), Missed route (15.22%), Wrong dose (13.04%) etc. The most common type of administration error was found to be Omission error (34.33%), followed by wrong time of administration of drugs (19.40%), etc. This is shown in Table 2.

Table 2: percentage & amount of prescription (n=92) and administration errors (n=67) per total orders in ED

Types of prescription errors	No. of drugs	Percentage (%)	Types of administration errors	No. of drugs	Percentage (%)
Wrong drug	6	6.52	Wrong drug	4	5.97
Wrong dose	12	13.04	Wrong dose	8	11.94
Wrong dosage form	10	10.88	Wrong dosage form	5	7.46
Wrong route of administration	12	13.04	Wrong route of administration	11	16.42
Wrong length of therapy	1	1.08	Wrong length of therapy	1	1.49
Wrong number of doses	2	2.17	Wrong number of doses	2	2.99
Illegible handwriting	15	16.31	Omission error	23	34.33
Missed route of administration	14	15.22	Wrong time	13	19.40
Missed dose	16	17.39
Missed dosage form	4	4.35

Drugs causing MEs:

Ondansetron (16.30%) was the drug which was high in prescription error and Enoxaparin (16.42%) was the drug which was high in administration error. This is shown in Table 3.

Table 3: Top drugs with Prescription (n=92) and Administration (n=67) errors in ED

Drugs	Frequency (%)
Drugs	Prescription errors	Administration errors
Azithromycin	11 (11.96)	9 (13.43)
Ondansetron	15 (16.30)	10 (14.91)
Metronidazole	8 (8.70)	5 (7.47)
Ofloxacin	3 (3.26)	2 (2.99)
Insulin	4 (4.35)	3 (4.48)
Ceftriaxone	6 (6.52)	2 (2.99)
Enoxaparin	12 (13.04)	11 (16.42)
Pantoprazole	10 (10.87)	8 (11.94)
Tramadol	7 (7.61)	7 (10.45)
Racecadotril	3 (3.26)	1 (1.49)
Others	13 (14.13)	9 (13.43)

Examples of medication errors:

Some examples of medication errors which were reported in emergency department shown in Table 4

NCCMERP categorization of MEs

Majority of medication errors were belonged to the category A (60.12%) followed by category C (19.63%), category B (14.11%), category D (3.07%), category E (1.84%) and category F (1.23%). This is shown in Table 5.

Table 5: NCCMERP categorization of MEs (n=163)

NCCMERP categorization	No. of drugs	Percentage (%)
Category - A	98	60.12
Category - B	23	14.11
Category - C	32	19.63
Category - D	5	3.07
Category - E	3	1.84
Category - F	2	1.23
Category - G	0	0
Category - H	0	0
Category - I	0	0

Dosage forms involved in MEs:

Types of dosage forms highly involved in medication errors at emergency department were injectable drugs (66.87%) and tablets (21.47%). This is shown in Table 6.

Table 6: Types of dosage forms involved in MEs at EM department (n=163)

Types of dosage form	No. of drugs	Percentage (%)
Injectable	109	66.87
Tablet	35	21.47
Capsule	2	1.23
Oral liquid	11	6.75
Other	6	3.68

DISCUSSION:

Medication use is a complex process that involves co-ordination among various health care professionals. Medication errors may happen at any stage of patient care like prescribing, administration, and dispensing.¹⁰MEs is defined as failure in the treatment process causing harm to the patient. An emergency department is among the most frequently visited departments of a hospital admitting only patients with critical and occasionally life-threatening diseases. Sudden unpredictable events occurring in an ED have made this place an environment known for its high potential for MEs; as a matter of fact, nearly 3% of all undesirable hospital accidents are related to this department.¹¹

Out of 220 cases 84 cases were found medication errors. Medication errors were most frequent for patients in the age group of (45–64) years and the age group to be least affected was (0–14) years. However, 2 patients affected by MEs were children between ages of 8 and 15 years. This is depicted in Table 1. In our study shows that male patients (64%) were more involved in MEs than female patients (36%). The results were almost like the study conducted by Patel S, Et. al which showed higher number of patients belonging to 41-60 years age groups.

Prescription errors was found to be the most common type of medication error in this study. The most frequently reported type of Prescribing Errors was Missed dose (17.39%) followed by Illegible handwriting (16.31%) etc. by the physicians. In our study the most common type of administration errors observed were omission errors (failure to administer or failure to record the administration, n=23) and wrong time (medication prescribed or administered in a time other than the recommended, n=13) followed by wrong route of administration (medications are prescribed or administered in a route other than the recommended, n=11), wrong dose (medication strength or quality different from that indicated, n=8), wrong dosage form (those errors in which no or inappropriate dosage form is indicated, n=5), wrong drug (drug other than the prescribed one, n=4), wrong number of doses (frequency of medication per day different from that indicated, n=2), wrong length of therapy (those errors in which no or inappropriate length of therapy is indicated, n=1). This is depicted in the Table 2. The results were almost like the study conducted by Zeraatchi A, Et. al which showed more than 60% of errors were prescription errors.

Ondansetron which is an anti-emetic drug used to prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, and surgery was found the most common prescription error drug. Enoxaparin which is in a class of medication called low molecular weight heparin, used to prevent, and treat harmful blood clots, was found the most common administration error drug. This is depicted in the Table 3. The results were almost like the study conducted by Hawaze S, Et. al which showed tramadol found top in prescription error and ceftriaxone the most common administration error.

NCCMERP taxonomy was used to analyses the categories of the medication errors. Most medication errors were belonged to the category- A followed by category- C, category- B, category- D, category- E and category- F. This is depicted in the Table 5. Example like Category – D: Large dose of Amoxicillin inadvertently prescribed for child patient. This study was almost like the study conducted by Bhowmick S, Et. al which showed majority of medication errors were belonged to the category- C.

Types of dosage forms highly involved in medication errors at emergency department were injectable drugs (66.87%) and tablets (21.47%). This is presented in the Table 6.

CONCLUSION:

MEs were found to be common in the tertiary care teaching hospital, especially in emergency unit as our study discovered from NMCH & RC, Raichur. In our study the majority types of errors we found prescription errors followed by administration error. Omission of the drug, dose, wrong time, wrong dosage form, wrong route was identified as common medication administration errors. Majority errors belong to NCCMERP category A followed by category C. Preventing medication errors should be the aim of every healthcare professional. We believe that every healthcare professional should be aware of these medication errors and overcome the all types of errors.

CONFLICT OF INTREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

Authors take it as a privilege to acknowledge Sri S R Reddy; Chairman Navodaya Education Trust, Medical Superintendent; Navodaya Medical College Hospital and Research Centre, Principal; NET Pharmacy College, in charge of the emergency department Dr. Shankarappa sir and the staff for their support during the study. Special thanks to Mr. Bhaskar, Biostatician for him valuable inputs in the study.

ABBREVIATIONS:

ED - Emergency Department;

MEs - Medication Errors;

HTN – Hypertension;

NCCMERP - National Coordinating Council for Medication Error Reporting and Prevention.

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Received on 13.05.2023 Modified on 19.10.2023

Asian J. Pharm. Res. 2024; 14(2):125-128.

DOI: 10.52711/2231-5691.2024.00021

Shiv Kumar1*, Santanu Mal2, Alfred Manoj3

MATERIALS AND METHODS:

Shiv Kumar¹*, Santanu Mal², Alfred Manoj³