4.1 Article

Current Situation of Medication Errors in Saudi Arabia: A Nationwide Observational Study

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JOURNAL OF PATIENT SAFETY
卷 18, 期 2, 页码 E448-E453

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LIPPINCOTT WILLIAMS & WILKINS
DOI: 10.1097/PTS.0000000000000839

关键词

preventable adverse events; medication errors; human factors; patient safety; Saudi Arabia

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This nationwide study quantifies the rate and level of harm from reported medication errors and identifies the stages of the medication process in which errors occur. It emphasizes the importance of pharmacists in reporting and detecting errors, and highlights the need for a blame-free culture and education for healthcare professionals to improve error reporting.
Objectives Medication errors are common and highly preventable events that significantly affect patients' health. This nationwide study primarily aims to quantify the rate and level of harm from the reported medication errors and to determine the medication process stages in which the reported errors occurred. Methods This retrospective observational study concerns medication errors reported to the General Department of Pharmaceutical Care database from March 2018 to June 2019. The database stores all aspects of medication error information, including patient, medication, and error information, along with the job position of the staff involved and contributing factors. The medication use process was categorized into these stages: ordering/prescribing, transcribing, dispensing, administering, and monitoring. We recorded each medication error based on categories from the U.S. National Coordinating Council for Medication Error Reporting and Prevention. Results A total of 71,332 medication error events were reported to the database. Physicians made 63,120 (88.5%) reported errors, and pharmacists most frequently detected the errors (75.9%). The majority of reported errors appeared at the prescribing phase (84.8%), followed by the transcribing (5.8%) and dispensing (5.7%) phases. A total of 4182 (5.8%) errors reached the patient. Health care professionals' work overload and lack of experience were associated with 31.6% and 22.7% of the reported errors, respectively. Conclusions Our study highlights the concern regarding medication errors and their low reporting by indicating that pharmacists reported and detected the majority of errors. Promoting a no-blame culture and education for health professionals is vital for improving the error-reporting rate.

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