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ORIGINAL ARTICLE

MEDICATION ERRORS AMONG GERIATRICS AT THE OUTPATIENTPHARMACY IN A TEACHING HOSPITAL IN KELANTAN

Dellemin Che Abdullah, Noor Shufiza Ibrahim, Mohamed Izham Mohamed Ibrahim*

Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Health Campus16150 Kubang Kerian, Kelantan, Malaysia. *School of Pharmaceutical Sciences, Universiti Sains

Malaysia, Pulau Pinang, Malaysia

The main aim of this study was to determine the medication errors among geriatricsat the outpatient pharmacy in a teaching hospital in Kelantan and the strategies tominimize the prevalence. A retrospective study was conducted that involvedscreening of prescription for a one-month period (March 2001). Only 15.35% (1601prescription) of a total 10,429 prescriptions were for geriatrics. The prescriptionsthat were found to have medication errors was 403. Therefore, the prevalence ofmedication errors per day was approximately 20 cases. Generally, the errorsbetween both genders were found to be comparable and to be the highest forMalays and at the age of 60-64 years old. Administrative errors was recorded to bethe highest which included patient’s particulars and validity of the prescriptions(70.22%) and drugs that available in HUSM (16.13%). Whereas the total ofprescribing errors were low. Under prescribing errors were pharmaceutical error(0.99%) and clinical error (8.68%). Sixteen cases or 3.98% had more than 1 error.The highest prevalence went to geriatrics who received more than nine drugs(32.16%), geriatrics with more than 3 clinical diagnosis (10.06%), geriatrics whovisited specialist clinics (37.52%) and treated by the specialists ( 31.07%). Theestimated cost for the 403 medication errors in March was RM9,327 or RM301per day that included the cost of drugs and humanistic cost. The projected cost ofmedication errors per year was RM 111,924. In conclusion, it is very clear that therole of pharmacist is very great in preventing and minimizing the medication errorsbeside the needs of correct prescription writing and other strategies by all of theheath care components.

Key words : medication errors, geriatrics, prescription screening, pharmacists, strategies to minimize

Introduction

Drug therapy in the health care system is notstatic but is a dynamic process. The introduction ofnew drugs in the market not only makes the therapymore sophisticated but also become complicated.However, this situation sometimes may lead toseveral problems in medication. Medication problemis potentially tragic and costly in both human andeconomic terms, for patients and professionals alike.Some will cause death to the patients. Statistics froma 1998 Journal of the American Medical Associationreported that, approximately 106,000 deaths occur

annually from medication, making adverse drugreaction (ADRs) the number 4 to 6 leading cause ofdeath in the United States; and over 2 million seriousADRs (defined as requiring hospitalization orcausing permanently disability or death) occurs eachyear(1).

In health care setting, there are manyproblems regarding drugs administration whichincludes administering the wrong drug, strength ofthe drug, or drug dose, confusion over “look-alike”and “sound- alike” drugs, incorrect routes ofadministration, miscalculations, misuse of medicalequipment, as well as errors in prescribing and

Submitted-18-2-2003, Revised-15-5-04, Accepted-30-5-04

Malaysian Journal of Medical Sciences, Vol. 11, No. 2, July 2004 (52-58)

53

transcription.Report in the professional literature and lay

press highlighted the humanistic and economicimpact of medication problems. Medicationproblems can lead to patient morbidity or mortality,and because drugs are used so frequently, the numberof preventable injuries are substantial (2). TheAmerican Hospital Association lists some commontypes of medication problems such as incompletepatient information, unavailable drug information,miscommunication of drug orders, which caninvolve poor handwriting, confusion between drugswith similar names, misuse of zeroes and decimalpoints, confusion of metric and other dosing units,inappropriate abbreviations, lack of appropriatelabeling as a drug is prepared and repackaged intosmaller units, environmental factors, such aslighting, heat, noise, and interruptions that candistract health professionals from their medical tasks(3).

On the other hand, medication errors representonly one of the many types of medication relatedproblems. The potential for adverse drug events andmedication errors is a reality. They occur in all partsof the medication use system, of which prescribingand administration reportedly account for a majorityof the errors(4)

Medication error is defined as any preventableevent that may cause or lead to inappropriatemedication use or patient harm, while the medicationis in the control of the health care professional,patient, or consumer. Such events may be related to

professional practice, health care products,procedures, and systems, including: prescribing;order communication; product labeling, packaging,and nomenclature; compounding; dispensing;distribution; administration; education; monitoring;and use (5) .

Medication error is not a new problem facedby the healthcare team. In fact, studies by Leapeand colleagues reported 3.7% of hospitalizedpatients experienced clinically significant adverseevents, with drug complications reported as the mostcommon single type of adverse event (19%) (6,7).Henri Manasse, Executive Vice President of theAmerican Society for Health-System Pharmacists,forecasted over a decade ago that drug-relatedmorbidity and mortality or “drug misadventure,”represented very serious medical problem anddeserved consideration as an issue of public policy(8,9). Johnson and Bootman further analyzed thescope of the medication-related problem. Theyreported that the number of drug-related hospitaladmissions ranges from 3.5 million to 8.8 millionannually, which corresponds to a hospitalization rateof 11.3% to 28.2% (10,11).

Medication errors can be classified as twomain types, prescribing errors and medicationadministration errors

In addition to under treatment, othermedication-related problems which occur ingeriatrics could involve improper medicationselection, too much or too little medication, failureto receive medication, adverse drug reactions, drug

Table 1: Prescription with Errors based on Demographic Data

MEDICATION ERRORS AMONG GERIATRICS AT THE OUTPATIENT PHARMACY IN A TEACHING HOSPITAL IN KELANTAN

Demographic Data

Gender

Race

Age

Geriatric Rx(%)

Rx with Error Prevalence(%)

Male 820 (51.22) 208 25.37Female 781 (14.78) 195 24.97

Malay 1263 (78.89) 299 23.67Chinese 311 (19.43) 93 29.90Indian 23 (1.43) 11 47.83Others 4 (0.25) 0 0

60-40 595 (37.16) 158 26.5565-69 396 (24.73) 103 26.0170-74 338 (21.11) 78 23.0875-79 154 (9.62) 35 22.73≥ 80 118 (7.38) 29 24.58

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interactions, and medication use with no indication(12)

Two studies conducted in New York and inColorado and Utah (13). The 1991 New York studyreported that adverse events due to medical errorsoccurred in 3.7% of hospitalized patients, with13.6% of the adverse events actually leading todeath. In the Colorado and Utah study, adverseevents occurred in 2.9% of hospitalizations, with8.8% of these resulting in death. Extrapolation ofthese data implies that between 44,000 and 98,000patients die each year as a result of medical errors,with an estimated overall cost to society of between$17 billion and $29 billion (14).

Therefore, this study was done to determinethe prevalence of medication errors among geriatricsin Hospital Universiti Sains Malaysia. As a part ofeconomic aspect, the expenditure loss due tomedication errors would be evaluated. Finally, thisstudy will identify the strategies to minimize themedication errors.

The study was conducted retrospectively atthe outpatient pharmacy department of HospitalUniversiti Sains Malaysia, Kelantan. All theprescriptions for the one-month period (March 2001)were audited and prescriptions that involved geriatricpatients were selected and screened. All the datawere collected using a form. The cost of drugs thatbeen involved in this mediation errors wascalculated. Drug errors were discussed with thedoctor in charge. One-month study was done due totime limitation.

Results

Demographic DataIn March 2001, 10,429 prescriptions were

screened at the outpatient pharmacy (from variousclinics) and from that amount 1,601(15.35%) arefor geriatrics. About 403(25.17%) from the whole

geriatrics prescriptions had medication errors.Therefore, the prevalence of medication errors thatcan be generated from this data was 25.17% whichwas approximately 20 cases per day excluding publicholidays.

This study showed that the prevalence ofmedication errors occurred was almost equalbetween male and female patients while based onrace, Indian patients recorded the highest prevalence.Patients at the age 60 to 64 years old had also showedthe highest case of having medication errors(Table1)

Medication Errors DataMedication errors were divided into 2

categories (Table 2). The first category was problemin administrative that could be divided into twoaspects. The first aspect that contributed 70.22% ofthe total medication errors was regarding patient’sparticulars and validity of the prescriptions thatinvolved miswriting either one or more of theparticulars like, patient’s name, registration number,date, age, gender, weight/height, ward/clinic,diagnosis and prescriber’s signature

Another aspect was drug availability inHUSM. Some drugs could not be dispensed thatcontributed 16.13% of the total medication errorswere because of non-standard drugs not listed inHUSM formulary, drugs that were nil in stock eitherstandard or sample and drugs that were restricted tobe prescribed by the specialists only .

Another category was prescribing errorswhich included pharmaceutical and clinicalproblems. Only 4 cases or 0.99% involved inpharmaceutical error which included dosage form,active ingredient, stability and appropriateness, aswell as method and special techniques.

While the clinical errors were, drug allergy,polypharmacy, drug-drug interactions, drug-diseaseinteractions, inappropriate dose and interval,

Table 2 : Distribution of Prescriptions According to the Type of Medication Error

Dellemin Che Abdullah, Noor Shufiza Ibrahim et. al

Type of Medication Error

Gender

Prescribing Errors

More than 1 error

Number of Error Percentage(%)

Patient’s particulars and 283 70.22Validity of the prescriptionsDrug availability 65 16.13

Pharmaceutical error 4 0.99Clinical error 35 8.68

16 3.98

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duplication of drugs, inapproriate drug regimens andno clear medical indication.

Sixteen cases had more than 1 error eitheradministrative errors only or prescribing errors onlyor both.

Economic DataThe cost of drugs that involved in medication

error was RM8,134. In order to determine the actualcost, the humanistic cost was also included. Itconsisted the total salary for pharmacists, pharmacyassistants and attendants which was RM30,900 permonth and RM2.96 per prescription. Since only 403prescriptions involved in medication error thehumanistic cost that been included was RM1,193.Therefore, it brought to the actual cost of medicationerror up to RM9,327 in March and RM301 per day.If the percentage of medication error was assumedto be equal in all month, the extrapolated cost ofmedication error was RM111,865 per annum

Discussion

In this study, Malays geriatrics were recordedas the highest involved in medication error.However, the prevalence was highest among Indianssince they are a minority race but the medication

errors often occurred.Even though the highest percentage of

medication errors are administrative errors, it shouldnot be neglected. For example, patients’ particularsare very important to ensure that the prescriptionbelonged to the right person. Therefore, themedication would be dispensed to the patientindicated. Validity of the prescription is anotherimportant aspect to determine the prescriptions arewritten by the legal persons. This indicates a needfor pharmacy and medical educators to furtheremphasize the importance of writing clear andcomplete prescriptions (15).

In this study, miswriting the diagnosis as apart of administrative errors was reported as the mostfrequent (73.8% or 277 cases). Therefore, thescreening processes were done by assuming themedication prescribed were indicated to the patients.However, before the medications were dispensed,the person who dispensed would asked the patientstheir problem or diseases in order to confirm eitherthe medications prescribed matched or not to thepatients.

Part of prescribing error, miswriting the druginterval such as for tablet Metoprolol 100mg (nointerval) and duration of the treatment like TabletErythromycin Ethyl Succinate 400mg bd (without

MEDICATION ERRORS AMONG GERIATRICS AT THE OUTPATIENT PHARMACY IN A TEACHING HOSPITAL IN KELANTAN

Number of Drugs

Number of Diagnosis

Prescibers

1-4 10795-8≥ 9

47646

1-23-4≥ 5Unwritten

1138169

7287

Specialist 354M/O 1247

Type of Clinical

Table 3 showed the distribution of medication error according to number of drugs and diagnosis, preacribers and type of clinics.

Outpatient 680A/ED/CSpecialist

17107797

Clinical Data Geriatric Rx

67.3929.742.87

71.0810.560.44

17.92

22.1177.89

42.471.063.68

52.79

Cases (%)

26312215

99170

287

110293

721

31299

Rx with Problem

24.3725.6332.61

8.7010.06

0

31.0723.50

10.595.88

28.9737.32

Prevalence

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duration), become as one of the pharmaceuticalaspect that had the highest prevalence. Whereas,most of the clinical errors involved drug over dosesuch as tablet Daonil® was prescribed more than20mg per day ( 10 mg tds).

The incidence of death and serious harmcaused by mistakes and accidents in medicationproblem is unacceptable. The patients have theirright to receive correct medical treatment. Thus, theresponsibilities and the role of screening prescriptionby the pharmacists should not be denied and theyshould actively involve in identifying and resolvingany medical errors.

The number of drugs between 1-4 was themost prescribed. As the number of drugs increased,the potential for medication errors occur might alsoincrease. Study showed that, geriatrics were likelyto have more than one diagnosis and drug. Thissituation might lead to more complication to thegeriatrics if medication errors occur.

Probably medications are the single mostimportant factor in improving the quality of life forgeriatrics but this population remains vulnerable tomedication error due to: (i) Physiological changesassociated with aging as for vital organs like renalfunction; (ii) Higher incidences of multiple chronicdiseases and conditions like hypertension, diabetismellitus and chronic obstructive pulmonary disease;(iii) Greater consumption of prescription and overthe counter medication.

Medication errors still remain as the criticalproblem to handle. The healthcare team consist suchas prescribers, pharmacists ,nurses and pharmacyassistants should give special attention and shoulduse their capability to minimize this errors.Estimated 1-2% patients admitted to the U.S.Hospital are harmed as a result of medicationproblems (16) and each problem results in additionalUS$5,000 cost, excluding legal cost (17). TheInstitute of Medicine (IOM) reports that 44,000 to98,000 patients die each year as a result of medicalerror (18).

Pharmacists are the important part of the riskversus benefit assessment process, because we seepatients when they get new prescriptions filled andany time they return for refilled. During theseinteractions, assessment of potential medicationproblems is possible. At outpatient pharmacy, thepharmacist should thoroughly check theprescriptions before dispensing the drugs. By thisway, any medical problems can be detected.However, it needs the pharmacists to spend all theirtime by doing the screening process. While the

pharmacy is the only place for patients to get theirmedication , the manually screening process mightno longer be suitable in the future.

The use of computerized system is looked asthe way that benefits both patients and pharmacists.Managerial level are urged to give attention becausecomputerized system will be able to do screeningprocess in a short time that make the job moreefficient. Strategies to reduce the incidence ofmedication problems frequently point to the positiveuse of technology equipment. Some medical centers(especially in western country such as US) havebegun using computer programs and other systemsupports to curtail medical mishaps by double-checking the care decisions doctors and nurses make.Even simple computer systems that use electronicprescriptions in place of handwritten ones have insome cases already paid off with substantial errorreductions. Hospital in the Department of VeteransAffairs, long notorious for serious lapses in medicalsafety, are now adapting bar-coded medication andidentification strips and wireless computertechnology after a study at two(2) VA hospitals inKansas found these devices reduced medicationerror rates by 70% over a five-year period (19).

In some cases different doctors prescribe samemedication (as previous doctor gave) to the samepatient. These situation not only waste the drugs costbut also, it can be harmful to the patients health.Therefore, beside technological advances, doctorshave their roles too. By checking patients’mediations profile and past medication historybefore prescribing also could avoid or at leastminimize medical errors.

Another way to minimize this problem is byregulating standard prescription writing by usinggeneric name and standard abbreviation. This willavoid any confusion to the pharmacist in order tointerpret the doctors’ handwriting. By using standarddrugs name and abbreviation it can avoid sound-alike and look-alike names. The FDA saw thissituation as a big problem. FDA is developing newstandards to prevent such name mix-ups, as well asto prevent confusion between similar-looking drugpackaging(20). However, the implementation ofelectronic prescribing will probably eliminate someof these problems (15).

Other aspect, which also can reducemedication problems is patients’ awareness abouttheir medication. In order to make them aware,education is very important. If patients concern whatthey are taking for their diseases, any changes totheir medication supply can be detected immediately.

Dellemin Che Abdullah, Noor Shufiza Ibrahim et. al

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In order to do so, counseling is thought as the bestapproach. Since patients are geriatrics this strategyhowever might not be effective. Alternatively,pharmacists could counsel the patients together withtheir family members. By this way, they can preventmedication problems by being vigilant about thehealth-care, understanding the treatment, keepingorganized records of what doctors they see and whatmedications they take and asking questions whenthings don’t seem right.

Another aspect that can reduce medicationproblem is to encourage participation of pharmacistsduring ward rounds. The availability of improvedcommunications with pharmacists, pharmacists onpatient care units, pharmacists on patient carerounds, drug information services, and pharmacistsas drug therapy consultants have consistentlydemonstrated improved patient outcomes and cost-effectiveness. Thus, to enhance and update theirknowledge the pharmacists should encouragethemselves to attend the continuous pharmacyeducation(CPE), conferences and courses. As forthat all organization and individual healthcareproviders should cooperate towards improve theutilization of these valuable resources.

Conclusion

The study concluded that medication errorsare still polemic for healthcare team because of itsimpact clinically and economically. It demandsongoing and vigorous attention for a long time. Thisindicates that the importance of correct prescriptionwriting by prescribers and prescription screening bythe pharmacists. However, other strategies to reducemedication errors still continue to minimize theprevalence of medication errors.

Further study should be carried out in orderto explore in depth about medication problemssituation in the hospital.

Acknowledgements

The authors wish to thank the staff of theOutpatient Pharmacy Unit and Aseptic DispensingUnit, Hospital Universiti Sains Malaysia for theirassistance and cooperation.

Correspondence :

Dellemin bin Che Abdullah B. Pharma (Hons),M.Pharma (USM)

Hospital Universiti Sains MalaysiaUniversiti Sains Malaysia, Health Campus,16150 Kubang Kerian, Kelantan, Malaysia

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