OBJECTIVES: To set up a medication error reporting and monitoring programme in a tertiary care hospital

METHODS: A prospective cohort study was conducted among patients aged ≥ 18 years hospitalised in a south Indian hospital over three years. On a daily basis, patients, patient's caregivers, and health care professionals (HCPs) were interviewed about the medication use process and patients' notes reviewed for identifying and evaluating outcomes of ME using the National Coordinating Council for Medication Error Reporting and Prevention standards. Root cause analysis was performed to understand the reasons and discussed with the relevant HCP to minimise the likelihood of recurrence of the ME

RESULTS: : A total of 1310 medication errors were reported among 20256 patients hospitalised and the incidences of medication errors were 6.4 for 100 patients. The common aetiologies of these MEs were administration errors 501(38.2), prescribing and transcribing errors together were 363 (28%) followed by dispensing and medication procurement errors 223 (17%) each. Clinical Pharmacist has reported 674 (51%) of errors followed by Nursing staff and Doctors 409 (31%) and 227 (17%). The majority of reported medication errors had an outcome of Category A 432 (33%) followed by category B 413 (32%). Root-cause of these MEs were distractions, excessive workload, and incoherent communications 472, 422, and 341 respectively. and patient related factors. The majority of the errors occurred during the late night shift hours 425 (32%). The length of hospital stay, the number of medications, multiple comorbidities, and work shifts were predisposing factors.

CONCLUSIONS: : Clinical Pharmacy established observational, prospective, voluntary, open, standalone, non-punitive, and anonymous reporting system was well received by other HCPs