Student Dissertation

Agency : Medication Error; Prescription Error; Audits

Objective : • To assess the medication process of the hospital under study. • To study the medication error rate for the study period. • To identify the cause of medication error. • To suggest various measures to prevent medication error in further if any.

Background : Medication error has been defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of health-care professional, patient or consumer. The error may be of commission or omission, with potentially negative consequences for the patient, which would have been judged wrongly by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences. Medication errors can be broadly considered to be of three types: prescribing errors, dispensing errors and administration errors.

Methodology : • STUDY SETTING – THUMBAY Hospital, HYDERABAD. • STUDY DURATION- 3 months • STUDY DESIGN – Prospective Observational Study • STUDY POPULATION – Patients visiting the hospital. • SAMPLE SIZE – 200 • SAMPLING METHOD – Non-probability convenience sampling • DATA COLLECTION – Observation of Case Sheet and nursing staff • DATA ANALYSIS – Using Microsoft Excel. Lean Sigma.

Findings : Out of 200 samples leaving the 12 samples of not having medication chart which sums up to 6% ; 37 % of documentation error was present, 46 % of prescription error among which (44 % of error cause of medicine not written in caps and 2 % because of medicine not legible), dosage error leads to 9 %, omission error occurred 3 %, nurses signature of 2 % , frequency error leads to 1% and the time error also reflects up to 1 %.

Recommendations : After completion of the study what I found is there is a lot of lack of knowledge among nurses and pharmacists which leads to a medication error, negligence and not only this, the use of short names like mgso4 instead of medicine name leads to a problem for nurses while transcribing the prescriptions at times. Doctor’s handwriting is illegible which very poor practice is. Unavailability of medicine is also an issue in the pharmacy. The stores are not being filled properly which leads to unavailability of drugs during the emergency and also when a patient requires. There is a major issue of lack of staffs in pharmacy which results to work-load and turns ending to wrong dispensing of drugs in rush like the look-alike drugs, or missing labeling of drugs .and also a shortage of nurses leads to workload pressure which results to delay in administering the drugs to the patients. Last but not the least dose error by doctors is found practiced which is a result of careless behavior. Solutions: • Monthly Training for Pharmacy and Nurses. And Especially New Joiners. • Request Doctors for Writing Properly and In Caps and Full Forms. • Request for Online Prescription • Checking of Re-Order Level. • Recruiting of New Staffs. • Proper Rechecking Before Administration. Suggestions and Recommendations: • Doctors should be sensitized continuously to avoid Prescription Error. • Nurses to be empowered to raise more of prescription error. • Regular audits of medication errors done by the multidisciplinary team. • Use of drugs in generic name within the hospital formulary. • E-prescription to reduce prescribing error from illegible handwriting. • Required number of Pharmacists and Nurses to be recruited to reduce the workload error. • Nurses should be requested to follow the patient identification protocol before administering concerned medicine to the respective patient. • Dispensing error to be reduced by proper education to the pharmacists and providing with adequate stock to avoid error non-availability of drugs respectively. • The adequate number of nurses and pharmacists along with health-care assistants should be made available to reduce workload.

Research Question: • What are the reasons for a medication error in the in-patient department? • How many cases of medication error is present?


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