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Towards patient safety: assessment of medication errors in the intensive care unit in a developing country's tertiary care teaching hospital
  1. Sri Harsha Chalasani,
  2. Madhan Ramesh
  1. Department of Pharmacy Practice, JSS College of Pharmacy Practice, JSS University, Mysuru, Karnataka, India
  1. Correspondence to Sri Harsha Chalasani, Department of Pharmacy Practice, JSS College of Pharmacy, Mysuru-570015, KA, India; csriharsha{at}


Objectives To determine the incidence, causes, patterns and outcomes of medication errors (MEs) in the intensive care unit.

Methods The ME reporting system was established using the principles based on prospective, voluntary, open, anonymous and stand-alone surveillance in a tertiary care teaching hospital located in southern India. MEs involving patients of either sex were included in the study, and the reporters were given the choice to remain anonymous. The analysis was carried out to determine the patterns, causes and outcomes of the reported errors and was discussed with healthcare professionals (HCPs) to minimise the recurrence of MEs.

Results A total of 292 MEs were reported voluntarily among 5137 admitted patients and the incidence of MEs was 5.6%. Administration errors (n=143, 49%) were the most common type of MEs reported followed by prescription errors (n=56, 19%) and dispensing errors (n=43, 15%). Factors responsible for MEs were related to performance deficit of HCPs due to excessive workload, fatigue, unclear interpersonnel communications and patient-related factors, which accounted for 37.6%, 13.1%, 9.6% and 7.7%, respectively. The majority of the reported MEs had an outcome of category C and A, based on the National Coordinating Council for ME Reporting and Prevention (NCC MERP) outcome category scale, amounting to 42.2% and 41.7%, respectively.

Conclusions Although the majority of MEs that reached the patients did not cause any harm, providing continuous education and awareness of MEs to HCPs and patients may minimise the scope of the factors that may contribute to MEs and improve overall patient safety.

  • Medication Errors
  • Medication Errors in ICU
  • Medication Errors in Developing Country
  • Medication Error Rporting Programme
  • Clinical Pharmacist initiated medication error reporting programme

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