DELVING DEEP INTO DETERMINING THE CONTRIBUTING FACTORS FOLLOWING THE REPORTED MEDICATION ERRORS

ABSTRACTIntroduction: Despite the existence of numerous frameworks to enhance medication safety, a number of factors have beenrecognized to be associated to medication errors (MEs) acting at both the individual and organizational/ system levels.Methodology: A prospective interventional study was carried out for a period of one year. All MEs occurring at any level inthe chosen specialties and any MEs reported by the healthcare professionals of any cadre were included into the study. Allthe MEs reported were classified according to their severity of the outcome using the NCC MERP Index.The concernedHCPs who were involved in the reported MEs were subjectively interviewed to identify what were the underlying factorsthat might have led to the MEs. The obtained responses were analyzed and deduced to determine theroot factors contributing to the reported MEs.Results: A total of 835 patients experienced 1567 MEs (incidence 1.9%). Amongst the study patients, 54.7% were malesand 45.3% were females. Doctors(49.7%) were the most common personnel involved in the majority of the reported MEs,followed by nursing staff(49.4%), and pharmacists (0.9%). A total of 8202 contributing factors(CFs) were identified for thereported MEs. The identified factors were broadly categorized into 16 main CFs such as work-related stress, peak workinghours, workload, emergency situations, fatigue, distractions, and so on.Conclusion: Fear of punishment and a prevailing ‘No-Blame’ culture in the work environment makes all healthcareprofessionals hesitant to report any MEs. The fear of disciplinary actions would pull them back, which might be the corereason for the under-reporting of MEs.