THE INCIDENCE OF PRESCRIBING ERRORS IN HOSPITALS AND ROLE OF PHARMACISTS IN MINIMIZING THEM ABSTRACT The frequency of drug prescribing errors is increased. The aim of this study is to estimate the types and prevalence of prescription errors reported most commonly in literatures. Retrospective analysis of incidence of prescribing errors was conducted over a period of June 2011 to January 2012. Not less than 150 prescriptions were collected from various hospitals of Karachi. Prescriptions were reviewed for their appropriateness by pharmacists. Results showed that incidence of prescribing errors is very high and 90% of prescriptions showed errors in the form of patient incomplete information, inappropriate drug and dose, route of administration, duration of treatment and failure to identify drug interaction. It has been concluded that prescription errors arise due to lack of knowledge of drugs and drug use in disease state management as well as lack of clinical pharmacy services in hospitals. The study highlights the need to pay attention that handwritten prescriptions should be replaced by computerized physician order entry. There is a need to critically address the legibility of prescription, correct spelling of drugs, authorized abbreviations and all other information of a prescription concerned with patient, prescriber and drug to minimize occurrence of medication or dispensing errors. It is also concluded that there is a good evidence to support pharmacist participation in hospital in minimizing mortality, morbidity and overuse of resources on drug related direct and indirect problems.
INTRODUCTION Drugs are the primary means of therapy for clients with health problems, but drugs may have the potential for causing harmful effects when administered improperly. Prescribing errors are one the most frequent types of medical errors among dispensing errors, medication administration errors, and patient compliance errors. A broad definition of prescribing error includes errors in decision making and errors in prescription writing (Dean et al, 2000). Prescribing errors involving decision making include a wrong choice for the patient (due to allergies, interactions between two drugs, presence of liver or renal failure, wrong molecule, dose or route of administration, etc.) as well as errors in prescription writing, involving illegibility, ambiguous abbreviations, lack of an important piece of information such as date of prescription, patient’s age, body weight, drug dose, route, frequency of administration, etc (Lesar et al, 1997). Since the latter can be more easily determined and detected through chart review, we focused our attention on them. Lesar et al. in 1990 reported that prescribing is an early point at which medication errors can arise. It has also been estimated that 1% of hospitalized patients suffer adverse events as the result of medical mismanagement and that drug related complications are the most common type of adverse event. The following are some ASHP guidelines on preventing medication errors suggested for physicians as well as for pharmacists because pharmacists also expected to play a pivotal role in preventing medication misuse. These guidelines include checks for : • Right patient, • Right drug, • Appropriate dosing schedule, • Appropriate route of administration,
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Correct route of administration for this patient, Pharmacists should never assume or guess the intent of confusing medication orders. If there is any question, the prescriber should be contacted prior to dispensing (American Society of Hospital Pharmacists, 1993). It is also suggested that pharmacist should collaborate with the prescriber in developing, implementing, and monitoring a therapeutic plan to produce defined therapeutic outcomes for the patient. (American Society of Hospital Pharmacists and American Nurses Association, 1980)
METHODS AND MATERIALS A retrospective study was conducted over a period of June 2011 to January 2012 by collecting prescriptions from outpatient department of physician clinics and from various hospitals of Karachi. For study purpose 155 prescriptions were collected from various sections including nephrology, neurology, pediatrics, cardiology and endocrinology. Prescriptions from ophthalmology and dermatology were excluded from the study since their prescribed medicines were mainly topical and administration route was not considered in this survey. Also prescriptions having fixed dose formulation were not included in the study to report dose errors. Every prescription was analyzed for its completeness (Patients’ age and weight, diagnosis, dose, frequency of administration and duration of therapy). Prescriptions were reviewed for their appropriateness by pharmacists.
RESULTS Out of 155 prescriptions only 5 prescriptions were considered as complete in all aspects for our study and are included for evaluation (n=150). Table# 1 shows the most common type of prescribing errors recorded in 150 prescriptions and their percentage of prevalence. Results showed a high prevalence of incomplete patients’ information including age and body weight (56% and 81.3% respectively). 48.6% (73/150) of prescriptions did not show diagnosis. Errors in inappropriate drug dose and frequency of administration were recorded same as 26.6% (40/150). 49.3% (74/150) of prescriptions did not describe duration of therapy.
DISCUSSION Medication errors are a source of considerable mortality, morbidity, and health-care costs today. Many of these errors originate in the prescribing stage of the medication use process. There are opportunities exist for pharmacists to intercept prescribing errors and to lead systems-based approaches to reducing their incidence We studied the incidence and nature of prescribing errors across various hospitals in the city of Karachi. Various types of prescribing error were identified in 96% of medication orders studied. Therefore, there is a need to explore the incidence and causes of errors on a local basis so that improvement strategies can be implemented. Results of our present study showed that among various common prescribing errors the most common type was failure to document patients’ body weight (81.3%) and age (56%). These two types of patient information are also of significance in calculating drug dose for a particular patient especially for paeds. Study showed that failure to describe end point of therapy was also commonly found in 49.3% of prescriptions which may result in drug-induced toxicities if medicines are not discontinued after the specified time. Data also showed that the incidence of prescription
errors with missed diagnosis (48.6%) was also very high which may be one of the cause of dispensing errors. When large numbers of prescriptions are written, human error inevitably leads to mistakes. However, unreadable prescriptions are perfectly safe because they cannot be dispensed without contacting the prescriber. A more distressing hazard is the confusion of similar names such as “thyroxine” and digoxine” or 'Indocid' and 'Inderal. So it is suggested that before dispensing and administrating medications to patients clinicians should be vigilant in writing prescriptions; nurses and pharmacists should be vigilant in checking prescription ( Ghaleb et l, 2006). Interventions which may help reducing medication errors include medication reconciliation, medication education programs, prescribing aids, practice guidelines, physician-pharmacist collaborative services, patient medication management reports, error reporting programs, and electronic prescribing in various care settings. (Institute of Medicine. Preventing medication errors, 2007).
CONCLUSIONS Being a highly qualified colleague and member of the primary care team pharmacists can act as a safety valve by protecting patients from unavoidable errors but unfortunately we are under-using his knowledge and skills.