IAJPS 2019, 06 (03), 5817-5824 Meshari Al Rayees et al ISSN 2349-7750

CODEN [USA]: IAJPBB ISSN: 2349-7750

INDO AMERICAN JOURNAL OF

PHARMACEUTICAL SCIENCES

Available online at: [Link] Research Article

REDUCING THE MEDICATION ERRORS USING

ELECTRONIC PRESCRIPTIONS
Meshari Al Rayees 1, Osama Mukhtar 1, Abdul Rahman Al Yousef2,
Attiya Bin Mohammad Al Zahrani3
1
CQI & PS Department, King Salman North West Armed Forces Hospital, Tabuk,
2
Supply Department, King Salman North West Armed Forces Hospital, Tabuk,
3
Hospital Director, King Salman North West Armed Forces Hospital, Tabuk.
Article Received: December 2018 Accepted: February 2019 Published: March 2019
Abstract:
Background: Medication errors are the main reason of the adverse events in a healthcare setup and it is a major concern of the
healthcare institution as it affects the quality of the care. The objective of the study is to evaluate frequency, type and severity of
medication prescribing errors in computerized prescriptions at the pharmacies in King Salman Armed Forces Hospital,
Northwest Region, Tabuk, Kingdom of Saudi Arabia.
Methods: It was a retrospective observational study conducted at Armed Forces Hospital Tabuk Saudi Arabia during the period
of six months (i.e. Jan 2018 to June 2018). A sample of 592 properly intervened prescriptions by the senior pharmacists was
included in the study. All the data was entered in SPSS v.21. Demographic and prescription related information was presented in
tabulated and graphical form by using their frequencies and percentages. Chi Square test was applied to find any association
between prescribing error severity and prescription related information in the prescription forms. Level of significance was taken
as 0.05 (p≤0.05).
Results: Of 592 prescriptions, 64.4% were taken from outpatients. Majority of the prescriptions were from Internal Medicine
department. Weight (81%) and diagnosis (39%) were the major missing details from the prescription. 393 (66%) of the
prescriptions were having dose related errors (under/over dose) while 247 (42%) were having frequency related and 36 (6%)
were route of administration related drug errors. On the basis of consequences caused by a drug error, 55% of the errors in our
study were minor error, 42% moderate and 3% were serious. A statistically significant association was reported between
prescribing error severity and prescription source (p=0.001) and specialty of physician (p=0.002).
Conclusion: Results of this study demonstrate that adding another protecting layer in the process of medication dispensing by
using a reliable design support system will be very useful for better patient safety and outcome. Moreover, pharmacy intervention
remains the key for quality improvement and patient safety in medication management.
Keywords: Medication Error, Electronic Prescription, Prescribing Error Severity, Saudi Arabia
Corresponding author:
Dr. Meshari Al Rayees, QR code
Director of Quality Improvement & Patient safety Department,
King Salman North West Armed Forces Hospital, King Abdul Aziz Military City,
Tabuk, Saudi Arabia,Cell: 00966505374673,
Tel: 0096614411088 Ext: 85982, 85981

Please cite this article in press Meshari Al Rayees et al., Reducing The Medication Errors Using Electronic
Prescriptions., Indo Am. J. P. Sci, 2019; 06(03).

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INTRODUCTION: the pharmacies in King Salman Armed Forces

A main reason of the adverse event in a health care Hospital, Northwest Region, Tabuk, Kingdom of
setup is “medication errors” and it particularly affects Saudi Arabia.
the Quality of care. One third of all the medical errors
in a medical facility belong to Medication errors [1]. METHODOLOGY:
It is a serious issue which challenges the goals of a It is a retrospective observational study conducted at
healthcare set up by causing harm and damage to the Pharmacy Department, King Salman Armed Forces
patient [2].A prescribing error is a failure in the Hospital Tabuk, KSA during a period of six months
process of writing a prescription by a physician and (i.e. Jan 2018 to June 2018). Approval for the study
this failure resulted in some wrong instructions for was obtained from the Research Ethic Committee of
the standard features of prescription [3]. The the hospital. By using Simple Random Sampling
“Standard features” of a prescription included techniques, a sample of 592 prescriptions was
Identity of the individual, drug identity, preparation, collected for the study. Medication orders generated
dose, the route, frequency, timing and period of in the computer during the operational hours of
administration [4]. Medication errors are different to pharmacy between these six months were intervened
an adverse drug reaction [5]. And all the steps and detailed reviewed by the senior pharmacist. Only
involved in the process of medical utilization those prescriptions were included in the study which
including prescribing, medication orders, packaging, were properly intervened by the senior pharmacist
taxonomy, dispensing, monitoring, using instructions and appropriately documented their comments in the
and administration are inclined to error [6]. The system. Any prescription, whose intervention was not
quality of healthcare has increased by the inclusion of clearly written, was excluded from the study. British
Electronic prescription system for medication in National Formulary and Dipiro’s Pharmacotherapy
healthcare set up. The electronic prescription for the were used as standards to substantiate correct
medication has reduced the medical errors by up to intervention by the pharmacist. The interventions
50% [7-8]. The literature showed that 72% of the and comments of the pharmacists were reviewed for
errors were started with prescription and 15% were respective error and classified in three categories of
observed in the administration [9]. Error Severity on the bases of seriousness of harms
results due to the medication error. Prescription
Prescription creation is a primary step in the errors were classified as (a) Minor error which has
medication process; so for the detection of the errors non-significant/potential inconvenient for patients,
and prevention of the patients from its effects, it is (b) Significant error has potential significant risk/
essential for the pharmacist and nurses to review the injury for patients, (c) Serious error has potential
orders and prescriptions [10]. In a systematic review serious/fatal risk for patients. All the data was entered
at Saudi Arabia which determined the incidence and in SPSS v.21. Demographic and prescription related
prevalence of different types of prescribing errors in information was presented in tabulated and graphical
adults, it was confirmed that the country has a very form by using their frequencies and percentages. Chi
high incidence rate of medication errors and it ranges Square test was applied to find any association
from minor to major [11]. The differentiation of between prescribing error severity and prescription
errors from minor to serious is subjects to their related information in the prescription forms. Level
adverse effect on the health of the patient. The of significance was taken as 0.05 (p≤0.05).
literature showed that the increasing incidence of
medication errors is a matter of concern for the RESULTS:
healthcare set ups of the whole world [12,13]. It was A total number of 592 prescriptions were included in
also reported by the Lewis PJ (2009) in his the study. Of these, 64.4% of the prescriptions were
systematic review in UK that in the secondary taken from Outpatients. 38.5% of the prescribing
healthcare setups the prescribing medication errors physicians were Registrars, while 37.7% and 23.8%
were a common practice [12]. Medication errors in were Consultants and Senior Registrars respectively.
the developing countries including Saudi Arabia are In the thorough review of the prescriptions, several
still under reported. These errors can cause deficiencies were reported in the patients’ detail on
significant harms to the patients such as adverse drug the prescriptions. (481) 81% of the prescriptions
event (ADE). The overall incidence of adverse drug were missing the weight of the patients and other
events and their effects in Saudi Arabia are still major missing patients’ details on the prescription
unknown [14]. The objective of our study is to were diagnosis (39%), age (29%) and gender (25%).
evaluate frequency, type and severity of medication Detailed results are presented in Table 1.
prescribing errors in computerized prescriptions at

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Table-1: Prescription related information

(a) Prescription details
Frequency Percentage
Inpatient 211 35.6%
Prescription source Outpatient 381 64.4%
Total 592 100%
Consultant 223 37.7%
Senior 141 23.8%
Designation of Physician Registrar
Registrar 228 38.5%
Total 592 100%
(b) Patients Details
Yes No Total
Prescription Number 589 3 592
Patient name 591 1 592
Hospital number 590 2 592
Department/Unit/Station written 527 65 592
Gender 442 150 592
Age 426 166 592
Weight 111 481 592
Diagnosis 359 233 592

The leading number of prescriptions was from Internal Medicine (34%) department. Family Medicine and
Cardiology were the other departments which having higher number of prescriptions (i.e. 15% and 10.1%
respectively) in our study. Number of prescription by each specialty is presented in Figure. 1.
Figure-1: Specialty of prescribing physician

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In Drug Related Errors, 393 prescriptions were of transmission and other 33% were having
having dose related errors. Of these, 81% were inappropriate route of transmission. Frequencies of
improper dosage and in 19% prescription, dose was drug related errors are presented in Table 2. Duration
omitted. Frequency related drug errors were found in of the therapy is another parameter observed in the
247 prescriptions. Of these 55% were having prescription. In this regard, 92% of the prescriptions
improper frequency and in remaining prescription, were having proper duration of therapy. Frequency of
frequency was missing. Drug errors related to Route duration of therapy and some other drug related
of transmission were found in 36 prescriptions. And parameters in the prescription is presented in the
of these, 67% prescriptions were not having any route Table 2.

Table-2: Drug related Information on Prescription

(a) Drug related Errors Improper Omitted Total

Dose (Under dose/Over Dose) 317 76 393/592
Frequency 136 111 247/592
Route of administration 12 24 36/592
Correct Incorrect Not written
(b) Duration of therapy specified
547 17 28
(c) Other parameters Yes No Not written
Drug without indication 11 576 5
Drug Interaction specified 4 583 5
Adverse drug reaction specified 33 554 5

More appropriate and/or available alternative

199 390 3
therapy

Allergy status mentioned 44 538 10

Status: CVS/Respiratory system/

41 540 11
Lung/Kidney
H/O intake of other medicine 288 293 11
Refill mentioned 328 262 2

On the basis of seriousness of harms caused by the drug errors, they were classified in three categories of
Prescribing Error Severity. 328 of the prescription interventions addressed the Minor medication errors. The other
two higher severity categories were Significant Errors and Serious Errors were reported 247 and 17 respectively.
Percentage of the categories of prescribing error severity is presented in Figure 2.

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Figure-2: Prescribing Error Severity

When the drugs which were involved in the medication errors were classified by ATC classification system, the
prescriptions which were having drugs for Alimentary Tract and metabolism were amongst the highest medication
errors. Results of the Drugs involved in medication errors are presented in Table 3.
Table-3: Drugs involved in medication error (ATC Classification System)

Drugs involved in medication error

(ATC Classification System) Frequency Percent

Alimentary tract and metabolism 108 18.2%

Blood and blood-forming organs 34 5.7%
Cardiovascular system 60 10.1%
Dermatological 50 8.4%
Genito-urinary system and sex hormones 9 1.5%
Systemic hormonal preparations 14 2.4%
General anti-infectives for systemic use 60 10.1%
Antineoplastic and immunomodulator agents 59 10.0%
Musculoskeletal system 24 4.1%
Nervous system 61 10.3%
Antiparasitic products, insecticides and repellants 3 0.5%
Respiratory system 13 2.2%
Sensory organs 22 3.7%
Various 75 12.7%
No ATC code 0 0%
Total 592 100%

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Chi Square test was applied to determine the was reported in designation of physician and
association between the prescribing error severity and prescribing errors (p=0.267). And a statistically
prescription source, Designation of Physician and significant association was found between
Specialty of the Physician. Minor and Significant prescribing errors and Specialty of the Physician
errors were reported significantly higher in outpatient (p=0.002). Detailed results of the statistical analysis
prescriptions (p=0.001). No significant association are presented in Table 4.
Table-4: Prescribing error severity in relation to different prescription information

Prescribing Error Severity

Minor Significant Serious p-value
328 247 17
Prescription Source
Inpatients 100 99 12
0.001
Outpatient 228 148 5
Designation of Physician
Consultant 117 102 4
Registrar 130 92 6 0.267
Senior registrar 81 53 7
Specialty of Physician
Internal Medicine 127 68 8
Surgery 17 13 0
Pediatrics 18 26 0
Family Medicine 56 32 1
Oncology 32 25 2
Obstetrics & Gynecology 12 8 0
0.002
Psychiatry 6 11 0
Dental 10 7 0
Cardiology 19 36 6
Renal 5 8 0
Anesthesia 2 1 0
ER 24 12 0

DISCUSSION: The most common prescribing drug related error in

Medication errors can be a reason of serious health our study was incorrect dose (66%) followed by error
problem which are related to the social and financial in the frequency (42%) and route of administration
consequences on the lives of the patients, healthcare (6%). The trend of the drug related errors is similar
professionals and health care organization and these with the literature [17-18]. But the percentage of
errors can lengthen the period of hospitalization and incorrect dose and drug frequency is higher than the
affects the treatment [7,15]. literature and it is an apprehension for the pharmacy
practice and should be addressed. The findings were
contradictory to a study conducted in Muscat focused
In our study, patients’ weight (81%) and diagnosis on outpatient pharmacy prescription, which reported
(39%) in the prescription were amongst the leading route of administration error as 26% followed by
missing details of the patient. The findings are incorrect dose error 20% [19].
comparable with the study conducted in Pakistan in
2015, which reported a missing of weight in 80% of In our study, duration of therapy was properly
the prescription and 37% missing information of the mentioned in 92% of the prescriptions. Duration of
diagnosis of the patient. [16] therapy was missing in 5% of the prescription. The
missing percentage of duration of therapy was

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reported very high in the literature as compared to involvement in the care plan for the patients.
our study [16,20]. However a study from Bahrain
reported 18.5% of the prescriptions were missing the • Use the data analysis of the intervention
duration of therapy, a more comparable finding with wisely to improve the service provided.
our study [21]. ACKNOWLEDGEMENT:
In calculating the severity of the prescribing errors, The authors would like to acknowledge the efforts
55% of the interventions of our study were and support of the Pharmacy Department of King
addressing the minor errors. 42% and 3% were Salman Northwest Armed Forces Hospital, Tabuk,
reported as significant (moderate) and Serious KSA in completion of this research.
(major) errors respectively. The trend is similar to the
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