Prevalence and Causes of Wrong Time Medication Administration Errors, Experience at a Tertiary Care Hospital, Karachi, Pakistan

Monday, 18 November 2013: 2:25 PM

Salimah Shamim Taufiq Kirmani, MSc Health Informatics, BSc Nursing
Aga Khan University Hospital Karachi, Pakistan, Karachi 74800, Pakistan

Learning Objective 1: Acknowledge the prevalence of wrong time medication administration errors and its contributing factors at tertiary care university hospital.

Learning Objective 2: Recognize the reliability of technology for identifying discrepancy of wrong time medication administration errors reported through voluntary incident reporting against electronic medication administration recording system.


Wrong time medication administration error (WTMAE) is a high risk to patient safety. It can result in severe harm, death or fatal consequences. No major study has yet focused on this issue. To help recognize and prevent such errors, technology has been developed such as the electronic medication administration record (eMAR) system which helps administering the medication on-time.


The purpose of the study is to investigate the prevalence of WTMAEs via eMAR and to explore the contributing factors of WTMAE.


A descriptive comparative study design with quantitative research approach was used for the study. The data was gathered from the nursing record of medication administration entered in eMAR system. The study was conducted at a private tertiary care university hospital in Karachi, Pakistan. The data was collected from adult medical, adult surgical, pediatric, intensive care unit and coronary care unit for 90 consecutive days.


Total 250,213 doses were observed out of which 231,380 doses were administered and 18,833 doses were not administered or were missing doses. Administered doses (n= 231,380) were further analyzed and identified for on-time administration (n=191,994; 83%) and wrong time administration (n=39,386; 17%). Study resulted highest percentage of WTMAE during the night shift. Data analysis for reasons of WTMAE exposed 50 different types of reasons for late administration and 9 different types of reasons for early administration.


Medication administration is a complex process and WTMAE another major area of focus. The study increased the evidence of the frequency of WTMAE and provided familiarities to nursing practices about multiple reasons for WTMAE. It proved the great innovation of technology in the form of eMAR and proved the reliability of eMAR over voluntary reporting system. The study highlighted major issues of Medication Administration Error that are necessary to deal with in the present time.