1. A study regarding prevalence of MEDICATION ERROR & its causes ; To
suggestbestpractices in MEDICATION SAFETY.
ABSTARCT:-
Introduction:
Medication safety is an issue worldwide .It is estimated that more than half of all medicines
over the world are prescribed, dispensed or sold inappropriately (WHO 2010). In high-income
countries, this has been recognized a long time ago and a lot of efforts are dedicated to improve
medication safety. If medications are not handled safely, it can lead to medication error.
Medication error can increase the cost, prolong hospital stay and increase the risk of death almost
two fold. Several studies have already demonstrated that clinical pharmacist can play major role
in detection, prevention of medication errors and improvement of quality.
Aim:
Present study was aimed to detect and evaluate the incidence, types of medication errors and to
rule out best practices for medication safety in AIMS FBD.
Method:
Prospective study was carried out from July 2014 to December 2014. Inpatients records of
patients from various departments were reviewed during their stay in the hospital. Detected
medication errors were documented and evaluated.
Results:-
A total of 1870 files were audited & 211 medication errors were seen. Maximum of
medication error (54) were detected in the month of July 2014. And out of these were22
prescription errors, administration errors were 61, dispensing errors were 2; out of this 124 were
documentation error. The causes of medication error were 88.2% were due to nurses,
10.40% were due to doctors and 0.98% errors were due to pharmacist. This study
concluded that 11.28% medication errors were detected during study period and revealed
that best practices of medication safety can play a major role in preventing these errors .

2. JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER
Series1 54 31 34 25 39 28
0
10
20
30
40
50
60
NUMBEROFMEDICATIONERROR
COMPILED DATA OF MEDICATION ERROR IN 2014
JULY AUGST SEPT OCT NOV DEC TOTAL %AGE
FILES AUDITED 315 304 304 315 311 321 1870
MEDICATION ERROR 54 31 34 25 39 28 211 11.28342
PRESCRIPTION ERROR 4 3 3 5 4 3 22 10.42654
ADMINISTRATION ERROR 22 9 6 8 8 8 61 28.90995
DISPENSING ERROR 0 1 0 0 0 1 2 0.947867
DOCUMENTATIONERROR 28 18 24 12 26 16 124 58.76777
TRANSCRIPTION ERROR 0 0 1 0 1 0 2 0.947867

3. MEDICATION ERROR:-
ACCORDING TO THE ROOT CAUSE ANALYSIS WE COULD FIND:-
10.42%
28.90%
0.94%
58.70%
0.94%
MEDICATION ERROR
PRESCRIPTION ERROR
ADMINISTRATION ERROR
DISPENSING ERROR
DOCUMENTATION ERROR
TRANSCRIPTION ERROR
88.62%
0.98% 10.40%
PROFFESSIONALS INVOLVED IN MEDICATION
ERRORS
MEDICATION ERRORS BY NURSES
MEDICATION ERRORS BY
PHARMACIST
MEDICATION ERRORS BY DOCTORS

4. ROOT CAUSE ANALYSIS SHOWED:-
REASON FOR MEDICATION ERRORS BY NURSES:-
 Untrained Nurses.
 Increased Workload on Nurses
 Tran scripting the Wrong Indent
 Tran scripting the wrong Standard timing
 H.A.L.T. (Hunger, Anger, Late, Tired )
 Environmental Issues : Dim Light, Noisy and disturbed Environment
 Documentation before administration of drugs OR Undocumented.
REASON FOR MEDICATION ERRORS BY DOCTORS:-
 Illegible Handwriting
 Out of List Abbreviation used
 Drug Allergies not identified
 Irrational drug combination prescribed
 Non-compliance of Right drug, dose, route, frequency, Time
REASON FOR MEDICATION ERRORS BY PHARMACY:-
 Misinterpretation of Prescription slip
 Confusion between LASA Drugs
 Increase number of IPD Patients results in Increase Work Load

5. FLOW DIAGRAM TO CLASSIFY THE INCIDENCE OF MEDICATION ERROR AND
ADVERSE DRUG EVENTS (ADE)
Incident
Medication Error
ADE with
medication
error
Potential ADE MedicationError
without potential
harm
ADE without
medication error
Severity Stage
Responsible
person
Stage
responsible
person
Severity
Disability
Preventability
Stage
Responsible
Person
Severe
Disability
INCIDENT FORM FILLED

6. Major Best Practices that can be suggested and are being followed is been listed through
INPUT OUTPUT PROCESS:-
INPUT PROCESS OUTPUT
ANTIBIOTIC RECORDING
POLICY
Mentioning day 1,day 2,day3 MONITORING OF ANTIBIOTIC DOSE
NARCOTIC POLICY Double Lock , Double Check , Double sign MONITORING OF NARCOTICS
PATIENT SAFETY
(HIGH ALERT POLICY)
High alert storage, single lock, double check
MONITORING OF HIGH ALERT
MEDICATION
VERBAL ORDER POLICY
Verbal order stamp, Verbal order to be written
within 24 hrs.
MONITORING OF VERBAL ORDER &
MEDICATION
MEDICATION RECORDS
Writing medication in capitals ,double check
every day by in-charges
LESS NO. OF MEDICATION ERRORS
QUALITY INDICATORS Frequent auditing by the Quality team IMPROVING THE RECORDINGS
PROPER MEDICATION
LABELLING OF LASA DRUGS
Labeling with date of opening & date of discard
Keeping drugs separate
REDUCE ERROR
PROPER RCA RECORDING RCA with proper reasoning
REDUCTION OF ERRORS

7. QUALITY AUDIT TRACKER Audits done by internal auditors
(E –MODULE )
TRACKING OF ERRORS
10 RIGHTS OF MEDICATION Instead of 7 R’s started to follow
10 R’s
REDUCTION OF MEDICATION
ERROR
ENGAGEMENT OF STAFF AND
MEDICAL PROFESSIONALS IN
QUALITY IMPROVEMENT
Involving trained personnel (educators
,doctors)
( NABH INTERNAL AUDITOR”S COURSE )
NOTIFY NC’S RELATED TO
EACH DEPT.
MEDICATION EFFECTS Notifying medication effects of each drugs PREVENTION OF ADVERSE EFFECTS
Use of SOCIALGROUP
(WHATS APP)
Involving nursing staff and quality team in one
group.
CIRCULATION OF ERRORS TO PREVENT
THE ERRORS
POST EVALUATION OF
MEDICATION MANAGEMENT
Competency assessment tool about medication
management frequently
EVALUATION ABOUT THE TRAINING
POST EVALUATION OF DRUG
CALCULATION
Competency assessment tool about drug
calculation frequently
EVALUATION ABOUT THE TRAINING

8. CONCLUSIONS:-
Medication errors are the serious problems in health care and can be the source of significant
morbidly and mortality in the health care setting. In India, irrational use of drugs is common and
this has led to antibiotic resistance, adverse drug reactions, medication errors and other drug
related problems. Drug therapies are important parts of medical care, contributing to medication
errors and other drug-related problems. Keeping up with the growing number of Prescription
medications are a major challenge for the physicians & documentation of medication by hand is
the major challenge for the nurses. Numerous studies have found that best practices of
medication safety to prevent medication errors. However, achieving true change has been a
challenge, and many hurdles still remain to be overcome.. A medication error is an episode
associated with use of medication that should be preventable through effective control system.
The factors that that increases the chance of medication errors are the attributes of complex
mechanisms involved in the prescribing, dispensing and administration of drug.
References:-
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