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Open AccessArticle

Evaluation of Medication Error Incident Reports at a Tertiary Care Hospital

College of Medicine, King Saud bin Abdul Aziz University for Health Sciences, Jeddah 21423, Saudi Arabia
Pharmaceutical Care Services, King Abdul Aziz Medical City, Jeddah 21423, Saudi Arabia
Saudi Medication Safety Center, Ministry of National Guard Health Affairs, Riyadh 11426, Saudi Arabia
College of Pharmacy, Ibn Sina National College, Jeddah 22421, Saudi Arabia
College of Pharmacy, Jazan University, Jazan 45142, Saudi Arabia
Author to whom correspondence should be addressed.
Pharmacy 2020, 8(2), 69;
Received: 21 February 2020 / Revised: 4 April 2020 / Accepted: 13 April 2020 / Published: 19 April 2020
Background: Medications errors (MEs) have been a major concern of healthcare systems worldwide. Voluntary-based incident reporting is the mainstay system to detect such events in many institutions. However, the number of reports can be highly variable across institutions depending on their adoption of the safety culture. This study aimed to evaluate and analyze medication error incidents that were submitted through the hospital safety reporting system in 2015 at a tertiary care center in the western region of Saudi Arabia, and to explore the most common types of harmful MEs in addition to the risk factors that led to such harmful incidents. Methods: This is a descriptive study that was conducted utilizing 624 medication error reports extracted from the hospital safety reporting system. Reports were analyzed based on the medication name, event type, event description, nodes of the medication use process, harm score (adapted from the National Coordinating Council for Medication Error Reporting and Prevention harm index), patients’ age/gender, incident setting, and time of occurrence as documented in the Safety Reporting System (SRS). Furthermore, all errors that resulted in injury or harm to patients had a deeper review by two senior pharmacists to find contributing factors that led to these harmful incidents and recommend system-based preventive strategies. Results: This study showed that most reported incidents were near misses (69.3%). The pediatric population was involved in 28.4% of the incident reports. Most of the reported incidents were categorized as occurring in the inpatient setting (57.4%). Medication error incidents were more likely to be reported in the morning shift versus evening and night shift (77.4% vs. 22.6%). Most reported incidents involved the dispensing stage (36.7%). High-alert medications were reported in 281 out of 624 events (45%). Conclusions: The hospital medication safety reporting program is a great tool to identify system-based issues in the medication management system. This study identified many opportunities for improvement in the medication use system, especially in management of chemotherapy and anticoagulant agents. View Full-Text
Keywords: medication error; incident reports; pharmacist medication error; incident reports; pharmacist
MDPI and ACS Style

Aseeri, M.; Banasser, G.; Baduhduh, O.; Baksh, S.; Ghalibi, N. Evaluation of Medication Error Incident Reports at a Tertiary Care Hospital. Pharmacy 2020, 8, 69.

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