Int J Clin Pharm (2013) 35:542–545 DOI 10.1007/s11096-013-9781-0
SHORT RESEARCH REPORT
Exploring health professionals’ experiences of medication errors in Saudi Arabia Mansour Tobaiqy • Derek Stewart
Received: 25 February 2013 / Accepted: 23 April 2013 / Published online: 7 May 2013 Springer Science+Business Media Dordrecht 2013
Abstract Background There is a paucity of literature originating from the Middle East on medication errors. Objective To explore the experiences of healthcare professionals around medication errors and medication error reporting. Setting Saudi Arabia. Method Questionnaire survey of those attending medication error continuing education sessions. Main outcome measures Experiences of medication errors in terms of number, type and severity in the preceding 12 months; barriers to reporting errors to health authorities; potential strategies to improve error reporting. Results Sixty-one (61/106, 57.5 %) questionnaires were completed. Thirty-five respondents (57.3 %) reported observing 51 errors during the preceding 12 months. Thirty-five errors (68.6 %) were described: wrong medication prescribed, dispensed or administered (11, 31.4 %); wrong dose prescribed (9, 25.7 %); inappropriate prescribing (issues of drug selection, monitoring) (9, 25.7 %); inappropriate route of administration (2), prescription duplication (2) and equipment failure (2). Patient outcomes resulting from these errors were described by the respondents as ‘caused patient harm’ in 14 instances. Three key barriers to reporting were: lack of awareness of the reporting policy; workload and time
constraints associated with reporting; and unavailability of the reporting form. Conclusion Findings indicate a potential need to review medication error reporting systems in Saudi Arabia to heighten health professional awareness and improve the reporting culture. Keywords Continuing education Medication errors Patient safety Questionnaire Saudi Arabia
Impact of findings on practice •
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Compromising patient safety due to medication errors is a key, global issue for all stakeholders in healthcare (patients, professionals, managers etc.). There is a clear need for review of education and training of all healthcare professionals in Saudi Arabia and the development of fully transparent reporting mechanisms which are efficient, providing usable and informative data. Qualitative work focusing on better understanding of the complex human behaviour around medication errors is urgently required.
Introduction M. Tobaiqy Ministry of Health, Patient Safety Department, The Maternity and Children’s Hospital, Jeddah, Kingdom of Saudi Arabia D. Stewart (&) School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK e-mail:
[email protected]
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Medication errors are ‘failures in the treatment process that lead to, or have the potential to lead to, harm to the patient’ and can occur at any stage of the patient medication journey during prescribing, administration and dispensing. Medication errors are classified in terms of mistakes (knowledge or rule based errors in planning an action), slips (erroneous performance) and lapses (memory based
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error in carrying out an action) [1]. Healthcare systems and processes which facilitate the identification, reporting and implementation of change to minimize medication errors are key in promoting patient safety. Rates of medication errors cited in the published literature vary widely due to a multitude of factors including inconsistencies in the definitions of ‘medication error’ or ‘prescribing error’, study designs and outcome measures. Tully [2] recently provided a narrative review around ‘prescribing errors’ in hospital highlighting the complex nature of errors and the lack of research on causal pathways, particularly key differences in those errors considered to be ‘major’ and ‘minor’. A systematic review of the prevalence, incidence and nature of prescribing errors in hospital inpatients published in 2009 concluded that such errors were a common occurrence, affecting 7 % of medication orders, 2 % of patient days and 50 % of hospital admissions [3]. Data from the United Kingdom, collated and reported by the National Health Service Patient Safety Agency for the period from October 2010 to September 2011, illustrate that medication errors are the second most common cause of patient safety issues (following patient accidents) during hospital stay, contributing to 11 % of all incidents, affecting 134,684 patients [4]. In a further systematic review, Ross et al. [5] reported the widespread nature of junior doctors’ prescribing errors. Error rates of between 2 and 514 per 1,000 items prescribed and 4.2–82 % of patients or charts reviewed were reported. Given the extent of these errors, there is an urgent need for clearly defined systems to fully document occurrences, allowing critical reflection and implementation of any necessary changes to prescribing practice. However, underreporting of errors is a characteristic of all self-reporting schemes [6]. Increasing attention is being given to the design and execution of health services research within Middle East countries. Alsulami et al. [7] undertook a systematic review of the literature on medication errors in the Middle East and noted that studies were relatively few in number and of poor quality. Given the global nature of medication errors, the World Health Organisation disseminated the ‘Multiprofessional Patient Safety Curriculum Guide’ in October 2011, articulating the need for education and training of all healthcare professionals on priority patient safety concepts and practices [8]. In line with these recommendations, seven education lectures on medication safety were delivered by a consultant pharmacist to healthcare professionals (nurses, pharmacists, pharmacy technicians and physicians) in public (general and specialized) hospitals in Jeddah city in the Kingdom of Saudi Arabia (KSA) between June and September 2011. Sessions focused on the identification and reporting of medication errors.
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Aim of the study This study aimed to explore the experiences of these healthcare professionals around medication errors and medication error reporting.
Methods One hundred and six healthcare professionals (nurses, pharmacists, pharmacy technicians and physicians) attended the sessions. An 11-item questionnaire was distributed to those willing to participate in the research immediately following the sessions; anonymity was assured. Options for questionnaire return were: to the researcher present at the session venues; return by post; or telephone call directly to the researcher. The questionnaire was developed from the literature on medication errors [1–8] and contained items on: experiences of any observed medication errors during the previous 12 months; nature of the errors; perceived barriers to reporting errors to the health authorities; potential strategies to improve error reporting; and demographics. Open and closed response items were included. The questionnaire was piloted with ten members of staff at the Maternity and Children’s Hospital, Jeddah, KSA. The study was approved by the Ethical Committee of Ministry of Health Research Centre in Jeddah. Data analysis was undertaken using SPSS (SPSS Inc., Cary, NC version 17.0) and comprised descriptive statistics.
Results Sixty-one (61/106, 57.5 %) questionnaires were completed by nurses (21), physicians [20, junior (10), specialist (7), consultant (3)], pharmacists (14) and pharmacy technicians (6). Thirty-eight respondents (62.2 %) were female and 23 (37.7 %) male. Thirty-five respondents (57.3 %) reported observing 51 errors during the preceding 12 months. Only two respondents (both pharmacists) confirmed that they had committed the error. Most errors were attributed to resident physicians (17, 33.3 %), specialist physicians (9, 17.6 %), consultant physicians (6, 11.8 %), nurses (6, 11.8 %), pharmacists (6, 11.8 %), pharmacy technicians (3), patients (2) and equipment failure (2). Out of 51 errors observed, 35 (68.6 %) were described: wrong medication prescribed, dispensed or administered (11, 31.4 %), wrong dose prescribed (9, 25.7 %), inappropriate prescribing (issues of drug selection and monitoring) (9, 25.7 %), inappropriate route of administration (2), prescription duplication (2) and equipment failure (2). Examples of medication errors are given in Table 1.
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Table 1 Examples of medication errors described by respondents Wrong medication prescribed, dispensed or administered
Inappropriate prescribing
CaCl2 administered instead of KCl for the management of diabetic ketoacidosis
Penicillin hypersensitivity was not documented on prescription chart, intravenous co-amoxiclav administered, patient transferred to intensive care with anaphylactic reaction
Patient prescribed Flixotide (fluticasone) metered dose inhaler and was given Seretide metered dose inhaler (salmeterol/fluticasone)
Child prescribed five different antimicrobials during stay in intensive care. Antimicrobials continued once diagnosis was confirmed as epilepsy
Doctor incorrectly prescribed Prozac (fluoxetine), should have been Proscar (finasteride)
Co-prescribing of atorvastatin and ezetimibe with insufficient monitoring
Prescription for Voltaren (diclofenac) was dispensed as Ventolin (salbutamol)
Co-prescribing of a fibrate and statin with no clear rationale
Fig. 1 Barriers to medication error reporting
Lack of feedback from authority Senior staff advised not to report Difficulty in recognising errors Concerns over penalisation Fear of blame Lack of anonymity Error too trivial Reporting system complexity Unavailability of reporting form Workload, time constraints Lack of awareness 0
2
4
6
8
10
12
14
Number of respondents
Patient outcomes resulting from these errors were described by the respondents as ‘caused patient harm’ in 14 instances. Five resulted in hospitalization of the patient, four led to prolongation of hospital stay, four were considered to have caused patient harm, but with no likely effect on duration of stay, and one patient was transferred to the intensive care unit. Just over half of these errors (19, 52.7 %) had been reported to the Total Quality and Management Department using the standardized reporting form, as per the local policy; 16 errors (45.7 %) were never reported. Barriers to reporting are given in Fig. 1. The three key barriers to which respondents strongly agreed or agreed were: lack of awareness of the reporting policy; workload and time constraints associated with reporting; and unavailability of the reporting form. Suggested strategies to improve detecting, reporting and reducing medication errors were continuing education events (lectures, symposia and conferences) (29, 51.8 %), an internet/web based reporting facility (22, 39.3 %), training focused on error prevention (22, 39.3 %), anonymity of reporting (14, 25.0 %), a
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non-punitive reporting culture (12, 21.4 %) and financial incentives linked to reporting (8, 14.3 %).
Discussion Findings suggest that medication errors occur in public hospitals in Saudi Arabia, with the majority of respondents observing an error in the preceding 12 months. Further key findings were the reported outcomes of the errors on patient safety and the low levels of error reporting. Data should be interpreted with caution. Participants comprised a convenience sample of healthcare professionals attending continuing education sessions drawn from only seven hospitals hence data may not be generalisable. In addition, participant numbers were low and data were based on self reports with inherent recall and social desirability biases. However, despite these limitations, it is clear that there are key issues in medication safety requiring attention. Our findings on nature of errors appear comparable with the limited research evidence base in the Middle East [7].
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Of note, more than half of the observed errors were never reported. This is in line with previous research which has identified under-reporting to be a common characteristic of all spontaneous reporting schemes and as such remains a major challenge for all professionals and healthcare authorities [6, 8]. Issues such as lack of awareness may be overcome by focused education and training commencing at the undergraduate level. Dudas et al. evaluated the impact of a patient safety curriculum on medical students’ attitudes towards patient safety. Despite a small sample size, significant changes were generated in questionnaire items relating to attitudes [9]. Given the multidisciplinary nature of healthcare, there may be value in interprofessional delivery as described by Galt et al. [10]. In Saudi Arabia, the Ministry of Health is establishing a patient safety department based in each hospital to monitor patient safety activities and to establish a patient safety culture. While this is both timely and to be applauded, there is an urgent need for high quality research to evaluate the impact of education, training and other patient safety initiatives on the frequency, nature and outcomes of medication errors. In particular there appears to be a paucity of qualitative work focusing on better understanding of the complex human behaviour around errors.
Conclusion Findings indicate a potential need to review medication error reporting systems in Saudi Arabia to heighten health professional awareness and improve the reporting culture. Acknowledgments We acknowledge the Ministry of Health and the Department of Health Directorate Affairs in KSA for reviewing and supporting this research. We also thank all health professionals in the seven hospitals who participated in this research.
545 Funding The research was funded by the Ministry of Health and the Department of Health Directorate Affairs in KSA. Conflicts of interest
There are no conflicts of interest to declare.
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