Underlying Factors of Medication Errors at a Tertiary Care Hospital, Pakistan

Purpose: Medication error is considered to be an important indicator of a patient’s safety. Several error producing factors contribute to its occurrence and may result in patients’ morbidity and mortality. Using a mixed method design, this study aimed to identify the underlying factors of medication errors. The study was conducted at a tertiary care hospital in Karachi, Pakistan.

Methods: Following the eligibility criteria, 64 medication errors, reported in this period from December 2011 to March, 2012 were included in this study. Data was collected by reviewing documents pertinent to the errors, a self-administered survey questionnaire, and face to face interviews with doctors, pharmacists, and nurses who had committed an error.

Results: Analysis of the quantitative data showed that of the 64 errors, 49 were actual errors, 15 were near misses and 2 were classified as sentinel events. The highest percentage of errors was committed in the administration phase, by nurses in the morning shift and they were working more than forty five (45) hours per week. The content analysis of the qualitative data led to two themes – stress and workload and the violation of policies.

Conclusion: These findings have implications for the hospital administration, and recommendations provided in this study will help them to bring an improvement in the system.

Keywords: Medication errors, factors, patient safety