An Observational Analysis of Medication Error in Tertiary Care Hospital

Pharmacy

Background and Aim: Medication errors (MEs) pose a critical challenge to patient safety in healthcare systems globally. This prospective observational study was conducted to assess the frequency, types, and contributing factors of MEs and drug-drug interactions (DDIs) in a tertiary care hospital setting. Methods: Conducted over a three-month period at Indus International Hospital, this study analyzed 200 prescriptions containing 1,339 drugs. MEs were observed during prescribing, transcribing, dispensing, and administration phases. The Drug Interaction Checker (drugs.com) was used to evaluate the severity of DDIs. Results: A total of 1,707 MEs were identified from 46,865 opportunities, resulting in an incidence rate of 3.64%. Prescription errors (50.6%) and administration errors (39.4%) were most prevalent, with illegible handwriting (31.3%) and dose omissions (20.9%) being the leading causes. Among 23 documented DDIs, moderate interactions (52.2%) were most common, with cardiovascular and CNS drugs being the most involved. Conclusion: This study highlights a significant prevalence of preventable medication errors and clinically relevant DDIs. Strengthening prescription protocols, incorporating computerized systems, and implementing formal error-reporting mechanisms are essential to enhance medication safety and reduce patient harm.

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