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Pharmacist-Initiated Medication Error-Reporting and Monitoring Programme in a Developing Country Scenario

1
Department of Pharmacy Practice, JSS College of Pharmacy, JSS Academy of Higher Education and Research, Mysuru 570015, Karnataka, India
2
Dean—Global Engagement, JSS Academy of Higher Education and Research, Mysuru 570015, Karnataka, India
*
Author to whom correspondence should be addressed.
Pharmacy 2018, 6(4), 133; https://doi.org/10.3390/pharmacy6040133
Received: 30 July 2018 / Revised: 30 November 2018 / Accepted: 5 December 2018 / Published: 14 December 2018
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Abstract

Medication errors (MEs) often prelude guilt and fear in health care professionals (HCPs), thereby resulting in under-reporting and further compromising patient safety. To improve patient safety, we conducted a study on the implementation of a voluntary medication error-reporting and monitoring programme. The ME reporting system was established using the principles based on prospective, voluntary, open, anonymous, and stand-alone surveillance in a tertiary care teaching hospital located in South India. A prospective observational study was carried out for three years and a voluntary Medication Error-reporting Form was developed to report medication errors MEs that had occurred in patients of either sex were included in the study, and the reporters were given the choice to remain anonymous. The analysis was carried out and discussed with HCPs to minimise the recurrence. A total of 1310 medication errors were reported among 20,256 hospitalised patients and the incidence was 6.4%. Common aetiologies were administration errors [501 (38.2%)], followed by prescribing and transcribing errors [363 (28%)]. Root-cause of these MEs were distractions, workload, and communications. Analgesics/antipyretics (19.4%) and antibiotics (15.7%) were the most commonly implicated classes of medications. A clinical pharmacist initiated non-punitive anonymous ME reporting system could improve patient safety. View Full-Text
Keywords: medication errors; clinical pharmacist; patient safety; medication incidents medication errors; clinical pharmacist; patient safety; medication incidents
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Chalasani, S.H.; Ramesh, M.; Gurumurthy, P. Pharmacist-Initiated Medication Error-Reporting and Monitoring Programme in a Developing Country Scenario. Pharmacy 2018, 6, 133.

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