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 »  Abstract
 » Introduction
 »  Materials and Me...
 » Results
 » Discussion
 » Conclusion
 » Acknowledgment
 »  References
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 Table of Contents    
Year : 2013  |  Volume : 45  |  Issue : 3  |  Page : 289-292

Noncompliance pattern due to medication errors at a Teaching Hospital in Srikot, India

1 Department of Pharmacology, Vir Chandra Singh Garhwali Govt. Institute of Medical Science and Research, Srikot-Srinagar, Pauri-Garhwal, Uttarakhand, India
2 Senior Program Officer, Lata Medical Research Foundation, Vasant Nagar, Nagpur, India
3 Department of Pharmacology, PGIMER, Chandigarh, India

Date of Submission12-Oct-2012
Date of Decision15-Jan-2013
Date of Acceptance26-Feb-2013
Date of Web Publication15-May-2013

Correspondence Address:
Heenopama Thakur
Department of Pharmacology, Vir Chandra Singh Garhwali Govt. Institute of Medical Science and Research, Srikot-Srinagar, Pauri-Garhwal, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0253-7613.111899

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 » Abstract 

Objective: To study the medication errors leading to noncompliance in a tertiary care teaching hospital.
Materials and Methods: This study was conducted in a tertiary care hospital of a teaching institution from Srikot, Garhwal, Uttarakhand to analyze the medication errors in 500 indoor prescriptions from medicine, surgery, obstetrics and gynecology, pediatrics and ENT departments over five months and 100 outdoor patients of medicine department.
Results: Medication error rate for indoor patients was found to be 22.4 % and 11.4% for outdoor patients as against the standard acceptable error rate 3%. Maximum errors were observed in the indoor prescriptions of the surgery department accounting for 44 errors followed by medicine 32 and gynecology 25 in the 500 cases studied leading to faulty administration of medicines.
Conclusion: Many medication errors were noted which go against the practice of rational therapeutics. Such studies can be directed to usher in the rational use of medicines for increasing compliance and therapeutic benefits.

Keywords: Irrational polypharmacy, lookalike sound alike, medication error rate, prescription

How to cite this article:
Thakur H, Thawani V, Raina RS, Kothiyal G, Chakarabarty M. Noncompliance pattern due to medication errors at a Teaching Hospital in Srikot, India. Indian J Pharmacol 2013;45:289-92

How to cite this URL:
Thakur H, Thawani V, Raina RS, Kothiyal G, Chakarabarty M. Noncompliance pattern due to medication errors at a Teaching Hospital in Srikot, India. Indian J Pharmacol [serial online] 2013 [cited 2023 Jun 6];45:289-92. Available from: https://www.ijp-online.com/text.asp?2013/45/3/289/111899

 » Introduction Top

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. [1] To err is human but to correct the mistakes after the same are pointed is scientific practice. 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. [2] There are 2,000 deaths every year from unnecessary surgery; 7,000 deaths from medication errors in hospitals; 20,000 from other errors in hospitals; 80,000 from infections in hospitals; and 106,000 deaths every year from non-error, adverse effects of medications. In all, 225,000 deaths occur per year in the US due to unintentional medical errors. [3] It is reported that nearly 98,000 people die annually, because of mistakes committed by medical professionals in hospitals in a ratio of 1:5 doses. [4],[5] Deaths in India, due to adverse drug reactions (ADRs) are estimated to be around 400,000 annually in 720,000 ADRs. USA has reduced ADRs to 1 in 3 doses.

Physician-Patient-Pharmacist relationship is the basis of a good prescription to ensure better compliance. The causes for medication errors can vary from miscommunication between physician, patient, pharmacist and other paramedical staff involved, to improper storage, labeling, packaging, confusion of look-alike sound alike (LASA), lack of information of current trends, protocols, dosing, references, medicine formularies or unawareness of the staff regarding new medicines, narcotics or high-alert medications. Other than this, other causes include human factors such as workload, fatigue, inexperience, lack of training, poor handwriting, and verbal orders; workplace factors such as poor lighting, noise, interruptions, excessive workload as well as pharmaceutical factors such as excessive prescribing, confusing drug nomenclature, packaging, or labeling, increased number or quantity of medicines per patient, frequency and complexity of calculations needed to prescribe, dispense, or administer a medicine and lack of effective policies and procedures.

At the patient level, the individual's clinical profile as well as the demographic status may influence compliance. The errors can range from faulty prescription to wrong administration or self-administration, illegibility, irrational polypharmacy especially, in geriatric population, faulty use of abbreviations or overwriting in prescriptions failing to comply with the six Rs' i.e., Right- patient, medicine, time, dose, route, and method.

 » Materials and Methods Top

This was a retrospective-cum-prospective, data based study conducted in Base Hospital of Vir Chandra Singh Garhwali Government Institute of Medical Science and Research Srikot, Garhwal, Uttarakhand, including only the acute cases where medicine was given by parenteral route or the injectable form for most of the illness, which itself is wrong in the first place. The retrospective arms of the study involved evaluation of 500 written prescriptions for medication errors in-patient tickets of the indoor patient departments (IPD) of surgery, medicine, gynecology, pediatrics, and Ear, Nose and throat (ENT) during previous 5months,whereas, the prospective arm studied 100 outdoor patients (OPD) from department of medicine for the medication errors in prescriptions and compliance. [Table 1]
Table 1: Types of medication errors in inpatient Departments of a Public Hospital in India (for compliance with six Rs')

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The medication error rate (MER) in prescriptions was formulated as:

(Number of errors observed/Opportunities for errors) ×100. [6]

Opportunities for errors = Total number of doses administered

Other formulae take number of drugs or number of patient days however, as a beginner at this location we took opportunities for errors as total number of doses administered as opportunities for errors.

 » Results Top

Maximum number of errors of 44 was noted in surgery department followed by medicine 32, obstetrics and gynecology 25, Pediatrics 10, ENT 1, in overall 500 IPD cases, which accounted for wrong doses of 336 in approximately 1500 doses calculated on this basis. The MER for IPD was found to be 22.4% and for OPD it was 11.4%.Number of errors in the above mentioned departments over 5 months is shown in [Figure 1].
Figure 1: No. of monthly errors observed in a total of 500 indoor patient departments prescriptions

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 » Discussion Top

With increasing health benefits, technology, and ease of access to medicines, there has been a collateral increase in the improper intake of medicines either due to the patients' own faults or due to mistakes of health personnel. It is not easy to speedily check the improper usage of medicines. Corrective measures need to be introduced to improve the drug delivery system and retard the incidence of medication errors. For scrutinizing, the steps from prescription to dispensing where the maximum chances of medication error is seen, we need to evaluate the whole process in the Base hospital, Srikot. Our study was an initiation towards correcting the MERs. The study was conducted keeping the major medicine utilizing departments in mind. Being a hilly region, it is common to find orthopedics and surgical patients besides the medical, obstetrics and gynecological cases in the hospital.

The implementation of all the six rights of rational pharmacotherapeutics was examined. Errors such as illegibility, irrational polypharmacy (especially, in geriatric population), absence of isolate report prior to prescription of antimicrobials, absence of sensitivity testing for medicines known to cause serious ADRs, missing pre-operative notes including pre-anesthetic notes, incomplete follow-up instructions, faulty use of abbreviations, use of similar sounding medicine names-LASA however, different effects, especially, in pregnant women, and overwriting in prescriptions were noted. Being a public hospital, prescribing generic medicine is necessary, and the list of available generic medicines is provided to all the physicians in the hospital. Herein overwriting, LASA, improper labeling and storing have more chances of leading to medication error. There is a multifold increase in population inflow in this region during summer due to pilgrimage season corresponding to the opening of shrines. Additional patient load with same attending staff leads to increased chances of errors in documenting and improper dispensing of medicines. There are more errors of administering wrong concentration and the duration due to the overload, the patients unwillingness to be hospitalized for long and physicians and other paramedical staff trying to provide early and quick medication.

On examining the case records, it was found that there were a lot of errors in the implementation of the six rights of rational therapeutics as reported by others too. [2] The Department of Surgery followed by medicine, obstetrics and gynecology collectively showed gross medication errors. The MER for OPD was 11% and 22% for IPD, which is nearly 4 and 8 times more respectively than the acceptable rate of errors. [5] Thus, the OPD needed administrative intervention to decrease MER, which was not carried out in this study, hence only observations have been reported. All the medication errors observed by us were leading to administration of wrong doses.

Another group established a relation between MER in increasing age of patients with increase in the number of medicines. [7] Yet another interventional study divided those responsible for MER into groups of physicians, nursing staff, pharmacists, and patients. [8] With successful implementation of corrective measures Apollo Hospital, Bengaluru reduced its MER to 1.46. [5] Similar intervention by competent authorities in our hospital to usher in corrective measures can improve the quality of health services and patient compliance to reduce MER. By keeping a check on the factors as shown in root cause analysis [Figure 2] the corrective measures can be taken.
Figure 2: Root cause analysis Schematic diagram showing occurrence of errors at various level

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The MER of 3% (older standard 5%) [4],[5] indicates that the facility has inherent problems with its medicine distribution system. The deficiencies need to be identified for bringing in the corrective measures.

Remote location, unwillingness to accept newer trends (inherent problems), personal benefit, public ignorance, general belief that injections are better, Standard treatment guidelines (STGs) not available to all the physicians, no regulatory body to keep a check and a general unawareness or negligence in considering medication error as a leading cause of mortality or non-compliance, fear of punishment and negligence by the prescribers and dispensers are limitation in reducing MER.

 » Conclusion Top

Study of medication errors in hospitals leading to non-compliance indicate, the problems existing in medicine administration. The data so collected can provide feedback to the administration, whose concentrated efforts may help in decreasing the medication errors thereby increasing the therapeutic benefits. [9]

Medication errors can also be prevented by establishing consensus group of physicians, nurses, and pharmacists to select best practices by introducing a punishment-free system to collect and record information about medication-related errors, developing written procedures with guidelines and check-lists for IV fluids and high-risk drugs (e.g., insulin, heparin, and narcotics), emphasis on legible handwriting and complete spelling of medicine name, using standardized notation, appropriately mention dosages ,use leading zero for values less than one and no trailing zero (e.g.,0.2 mg instead.2 mg; 2 mg instead of 2.0 mg) mentioning route of administration on all prescription, completely written directions (e.g.,"daily" not "Quaque die everyday (QD)" or "Omne in die everyday or once a day (OD)"), limiting use of telephone and verbal orders to emergency situations, reconfirming identity of patients before administering medication, use standard administration times for hospitalized patients, for LASA names-establish a policy requiring that prescribers write both brand and generic names, use pharmacy staff to help prevent errors. [10],[11] Sloppy handwritten prescriptions should be replaced by computerized physician order entry, a very effective technique for reducing prescribing/ordering errors, however, another far less expensive yet effective change would involve writing all drug orders in English, rather than continuing to use the elitists'Latin words and shorthand abbreviations that are subject to misinterpretation. [12],[13],[14] Last of all but not the least:a point of concern is how to disclose the error. Thus disclosing the error also becomes an act of heroism as doctors have high expectations of themselves and find it difficult to acknowledge their errors openly in front of patients, attendants and colleagues. [15]

Other hospitals also need to be sensitized towards medication errors. A need to establish monitoring committee or program with a link to drugs and therapeutic Committee-WHO, where monthly reporting should be mandatory is also recommended.

 » Acknowledgment Top

We thank Deputy Medical Superintendent (DMS) Dr. V Gusain and Chief of the Medical Records section Mr. Uniyal for providing us free and easy access to the records for data collection.

 » References Top

1.National Coordinating Council for Medication Reporting and Prevention (NCCMERP), 2005 Available from: http://www.nccmerp.org. [Last accessed on 2012 Apr 07].   Back to cited text no. 1
2. Harris MH. To err is human - The fallible physician. S D J Med 2004;57:9-11.  Back to cited text no. 2
3.Iyer M. Medical errors in top 10 killers: WHO, 2011. Available from: http://articles.timesofindia.indiatimes.com/2011-04-20/india/29450526_1_medical-errors-patient-safety-negligence.[Last accessed on 2012 May 18].  Back to cited text no. 3
4.Reddy LK, Modi AG, Chaudhary B, Modi V, Patel M. Medication errors-A case study. J Acad Hosp Adm 2009;21:28-34.  Back to cited text no. 4
5.Pathak P. Reducing Medication error. Express Healthcare, 2008. Available from: http://www.expresshealthcare.in. [Last accessed on 2012 May 18].  Back to cited text no. 5
6.Roy V, Gupta P, Srivastava S. Medication errors: Causes & prevention. Health Administrator 2006;19:60-4.  Back to cited text no. 6
7.Pote S, Tiwari P, D'Cruz S. Medication prescribing errors in a public teaching hospital in India: A prospective study. Pharm Pract2007;5:17-20.  Back to cited text no. 7
8.Khowaja K, Nizar R, Merchant RJ, Dias J, Bustamante-Gavino I, Malik A. A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan. Ther Clin Risk Manag 2008;4:673-9.  Back to cited text no. 8
9.Adubofour KO, Keenan CR, Daftary A, Mensah-Adubofour J, Dachman WD. Strategies to reduce medication errors in ambulatory practice. J Natl Med Assoc 2004;96:1558-64.  Back to cited text no. 9
10.Laing R, Hogerzeil H, Ross-Degnan D. Ten recommendations to improve use of medicines in developing countries. Health Policy Plan 2001;16:13-20.  Back to cited text no. 10
11.Pharmaceutical services division. Medication error reporting form and flowchart. Guideline on Medication Error Reporting. Ministry of Health Malaysia, 1 st ed; c2009:12-17. Available from: http://www.moh.gov.my/images/gallery/Garispanduan/Med_Erro/MERS_Guideline_Final.pdf. [Last accessed on 2012 Apr 08].  Back to cited text no. 11
12.Benjamin DM. Reducing medication errors and increasing patient safety: Case studies in clinical pharmacology. J Clin Pharmacol 2003;43:768-83.  Back to cited text no. 12
13.Rothschild J. Computerized physician order entry in the critical care and general inpatient setting: A narrative review. J Crit Care 2004;19:271-8.  Back to cited text no. 13
14.Guy J, Persaud J, Davies E, Harvey D. Drug errors: What role do nurses and pharmacists have in minimizing the risk? J Child Health Care 2003;7:277-90.  Back to cited text no. 14
15.Kalantri SP. Medical errors and ethics. Indian J Anaesth 2003;47:74.  Back to cited text no. 15


  [Figure 1], [Figure 2]

  [Table 1]


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