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4CPS-162 ‘To err is human’ – presenting cases of medication errors from real clinical practice
  1. S Stoev1,
  2. S Belcheva2,
  3. T Todorova2,
  4. N Veleva2,
  5. H Lebanova2
  1. 1Medical University Pleven, Pharmaceutical Sciences and Social Pharmacy, Sofia, Bulgaria
  2. 2Medical University Pleven, Pharmaceutical Sciences and Social Pharmacy, Pleven, Bulgaria


Background and Importance Medication errors (ME) are preventable mistakes or incidents that can occur at any stage of the medication use process, which can cause patient harm and significant morbidity and mortality.

Aim and Objectives Identification of the nature, incidence, and potential preventative measures of DRPs. To evaluate the role of the pharmacist in ME risk reduction process and to identify critical points and outline strategies to reduce iatrogenic ME.

Material and Methods The current prospective direct clinical observation was carried out in the period June- December 2022 by analysing the electronic records of 1625 patients in a specialised gynaecological hospital with national coverage. Participants were also interviewed by a clinical pharmacist to verify the information extracted from the electronic records.

Results The average number of medications per person was five, and the median age of the cohort was 36 years. In 1/3 of the cases, the therapy consisted of both drugs and supplements. The desired therapeutic outcome was achieved in 320 of the records, while treatment was discontinued in 569. The highest number of ME was observed in the age group >40 years, followed by 31–40 years. Parenteral products accounted for 68% of the errors. Categories of ME identified were: administration, prescribing, dispensing, drug interactions, patient error, and other. Inadequate recording of prescription details in the electronic hospital system accounted for most of the identified errors. Misuse, followed by inappropriate choice of drug/dose or duration of treatment, and inappropriate route of administration are among the most common DRPs identified. In only 12% of cases was the error identified and the associated harm prevented as a result of a physician-initiated consultation with the hospital pharmacist. The physician’s acceptance of the pharmacist’s suggestions was >80%.

Conclusion and Relevance Although hospital e-prescribing systems are seen as a tool to reduce prescribing errors, the above cases demonstrate that these systems alone are not sufficient to significantly reduce the risk of inappropriate prescribing. Hospital pharmacists can be considered as a valid checkpoint to effectively reduce DRP.

References and/or Acknowledgements 1. The project is funded by the European Union- NextGenerationEU; procedure ‘Creating a network of research universities’ from the National Plan for Recovery and Resilience, project ‘Research University- Medical University-Pleven’, contract #BG-RRP-2.004–0003-C01.

Conflict of Interest No conflict of interest.

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