Medication Error patients Admitted to Medical Ward in Primary Hospital,

Ethiopia: Prospective Obserbetional Study

Bezie Kebede 1* Email: [email protected]
Yitayih Kefale2 Email: [email protected]

1. Mizan-Tepi University, College of Health Science, Department of Pharmacy

2. Bahir Dar Health Science College, Department of Pharmacy
Abstract
Background: Medication error (ME) is broadly defined as any error in the prescribing, dispensing, or
administration of a drug. ME is the single most preventable cause of patient harm. An infinite number of
medication error exist because of the rapidly expanding array of drug products available, the growing number
of diseases being recognized & diagnosed, and the growing number of patients entering the health care system.
Purpose of study: Since medication error is the most common problems in hospital and community setting and
has substantial clinical, social and economic impact. Therefore, identification of determinant factors for ME has
paramount importance in preventing of unnecessary outcome.
Objective: To evaluate the most frequently encountered drug class undergo medication errors, identify
sources of medication error and evaluate predictors of medication errors among patients admitted to
medical ward in primary hospital, northwest Ethiopia.
Method: Prospective observational study was conducted from April 1/2018-October/2019G.C. All adult
patients who met inclusion criteria were included in the study. Patient medication adherence was evaluated
using morisky adherence scale. Independent predictors of outcome identified and strength of association
between dependent and independent variables determined by using binary logistic regression analysis and
statistical significance was considered at p<0.05.
Result: A total of 260 patients were included in the study. Of which 162 (55.7%) were males. Overall response
rate was about 97%. Among these, majority of them were encountered medication errors. Average number of
drugs per day for a patient was 3.5. Ant-infective drugs were mostly prescribed as well as medication error
encountered. Unnecessary drug therapy is the most common error. Proportion of patients with medication error
is lower among patients who are on 1-3 drugs as compared to those patient who are on more than five
drugs(p=0.025). Patients who stayed less than one week less likely encountered medication errors as compared
to those stay more than a week(p=0.024).
Conclusion: Medication error is very prevalent in this hospital and unnecessary drug is the most common ME.
Length of hospital stay, number of medication availability are determinant factors for medication errors. Since
medication availability is significant determinant for medication error, hospital should try to avail medication and
prevent medication errors. Clinical pharmacists should involve in multidisplinery team and continuous patient
medication reconciliation should be integral part of patient medical management.

Key-words: Medication error, Primary Hospital, Medical ward

1
 .
Background
Medication error (ME) is broadly defined as any error in the prescribing, dispensing, or
administration of a drug. ME is the single most preventable cause of patient harm (1). ME is also
defined as, ‘The failure of a planned action to be completed as intended or use of a wrong plan to achieve an
aim’ (2)
MAE is one of the risk areas of nursing practice and occurs when a discrepancy occurs between
the drug received by the patient and the drug therapy intended by the prescriber (3).
An infinite number of medication error exist because of the rapidly expanding array of drug products
available, the growing number of diseases being recognized & diagnosed, and the growing number of
patients entering the health care system (4)
It would be much better to prevent medication errors than to correct them. But this is not always possible
because of the complexity of pharmacotherapy, lack of training and knowledge of health care providers
and the behavior of drug users(5).
The Institute of Medicine report implicates (MEs), at least in part as a direct cause between 44,000 and
98,000 patient deaths annually in the United States. The global burden of MEs results from all types of
adverse events which includes prolong hospital stay, financial burden, disability, morbidity and
mortality(6).
Errors can occur at any stage of the process; from medication selection and ordering, to order
transcription, drug formulation, drug dispensing and administration(7). The role of the nurse in
medication management has developed exponentially over time. However, the fundamentals of the
nurse’s role in medication management remain unchanged and nurses are expected to deliver and
execute the highest standards of care and safety when it comes to medication management. Nurses
represent the last safety check in the chain of events in medication management and therefore the final
safeguard of patient wellbeing and potentially the difference between achieving the desired outcome and
harming the patient(8).
MEs that result in catastrophic events may result from combined efforts of “latent failures” in the
system and “active failures” by individuals working in that system. Efforts are being made globally to
establish systems capable of collecting accurate and relevant medication error data, which may provide
valuable information needed to minimize MEs (9). Various studies were conducted in the drug
therapy problems done in Ethiopia but medication error was not done till know. This paper can be used
as a base line to do further research concerning medication error. This finding also used to identify the
sources of medication error and give appropriate and immediate feedback.

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 Methods and participants
This study was conducted in Alem Ketema Enat Hospital, Ethiopia. Alem Ketema Enat Hospital is
located in Alem Ketema town which is 185km far from the capital city and it is found northwest Ethiopia.
It is one of health institutions established by ‘‘Karl Henze’ in 1996 in north shewa. It is offering diagnosis
and treatment for more than 70,000 patients per year. There are about four inpatient services located
within the hospital which serve more than 200 admission/month. Among this, about 100 patients are
admitted to medical ward per month (10). This study was conducted specifically at medical ward
service from April 1/2018-October/2019G.C.
Hospital based prospective observational study was used to assess medication error among patients
admitted to internal medicine ward. All adult with age 18 and above patients admitted to medical ward from
April 1 -February 10/2011 ward and who are willing to participate were considered as the study population.
Finally all adult patients who satisfy the inclusion criteria were candidate as a subject for the study.

Selection of study participants

Total patients admitted to medical ward (N=270) (April-October, 2019)

 Refuse to participate
(n=10)

Included in the
analysis(n=260)

Fig.1: Summary of sampling procedure

As shown in fig.1, all adult patients who met inclusion criteria and presented to hospital in the data
collection period were recruited.

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 Data collection procedure and analysis
Relevant information like patient characteristics, current medications, co-morbidities, number of drugs,
length of hospital stay, availability of drugs in the hospital and adherence(assessed by morisky adherence
scale) were recorded using structured questionnaire (adapted from different published literature . Relevant
data was obtained by interviewing the patient and chart review when necessary.
Medication error was dichotomized as error free and presence of errors. Before actual data collection, pre-
test was done on 5% of patients in order to check language barrier, if there is missed variables, readability,
and ease of understanding. Data was collected by two pharmacists and one Nurse under supervision of one
medical doctor after two days training about objective of study and how to filter data from patient
chart/card. Supplementary information and clarifications on some patient’s medical information was
obtained through discussion with respective nurses and physician. Guidelines concerning MEs were
distributed for data collectors. Naranjo scale and Micro-medex version 3.1 were used to evaluate adverse
drug reaction (ADR) and drug interaction (DI) respectively.
Data was entered into a computer using Epi data 3.1software and analyzed with SPSS version 23. Before
analysis, presence of co linearity between independent factor (having less than 2.5 variance inflation factor)
and model fitness (with Hosmer lemeshow p-value 0.136) were checked. Chi-square statistics were used to
check adequacy of cells for binary logistic regression. Independent predictors of outcome and strength of
association between dependent and independent variables was identified by using binary logistic regression
analysis and P-value < 0.25 entered to multiple regression. P value < 0.05 was considered as significant.
Descriptive statistics was used to characterize ME and independent variables. Results of the study were
organized in the form of frequencies and percentages. The data was summarized and described using tables
and figures.
Results
Background characteristics of participants
A total of 260 patients were included in the study. Of which 162 (55.7%) were males. Overall response rate
was about 97%. The mean age was 38.5 (age range 18-85) years with the maximum number of patients
being in the age group of 41-59 years. Majority of patients 180 (69.23%) were found to have 1-2 co-
morbidities and ≥3 co-morbid illnesses 53(20.38%). Only 37(14.23%) were without any co morbidity. A
total of 989 medications were prescribed. Average number of drugs per day for a patient was 3.5. Majority
of the study subjects (47.5%) received 2 to 5 drugs per day. The details of patient demographic
characteristics along with other factors that may influence ME like number of co-morbidity, length of

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hospital stay, unavailability of medication and average number of drugs received per day are shown in
Table 1.

Table 1: Socio-demographic and clinical characteristics of participants, medical ward, Enat Hospital,
Ethiopia, 2019

Socio- Category Number Percent Mean + SD Range

demographics and
characteristics of
patient
Sex Male 162 62.3
Female 98 37.7
Age group 19-40 84 32.3 38.5±13 18-85
41-59 120 46.15
60-75 56 21.55
Co morbidity Yes 37 14.23
No 223 85.77
Hospital stay <1 week 145 55 5±2.3 4-35
≥1 week 115 45
Number of drugs 1-3 90 34.62 3±1.4 1-5
received/patient 3-5 130 50
≥5 40 15.38
Is the drug Yes 170 65.38
available? No 90 34.62
As it is indicated in figure 2 below, disease distribution of the study subjects showed a higher prevalence of
infections (36.1%) followed by Congestive heart failure (20.5%), diabetes mellitus (13%), hypertension
(12.4%), dyspepsia (9%), asthma (6%), and others (3%).

5
 40.00%

Percentage of patients
30.00%
20.00%
10.00%
0.00%
on F
DM
N sia a rs
cti CH HT ep th
m
the
fe sp A s O
In Dy
Disease categorys

Fig. 2 Disease distribution among study subjects, Enat Hospital, Ethiopia, 2019

Among all 989 drugs prescribed, anti-infective were 567, cardio vascular drugs were 213, anti-diabetics
drugs 197, GI (gastrointestinal) drugs 123. As shown in fig. 3 the most frequently prescribed drugs were
ceftriaxone 405 (40.95%), furosemide and spironolactone 217(21.94%) each, metronidazole 129 (13%)
glibenclamide 118(11.93%), salbutamol puff 65(6.5%), and cimetidine 55(5.68%).

40.00%
Percentage of drugs

30.00%
20.00%
10.00%
0.00%
ne e le e ff
id zo id pu ne
xo m a m l di
ria ro
se
ni
d cla
m
o eti
Ce
ft
Fu ro b en uta Ci
m
et gl i lb
M sa
Drugs prescribed

Fig. 3 the most commonly prescribed drugs, Enat Hospital, Ethiopia, 2019

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 Prevalence of medication errors

MEs were found in 62 % of the study subjects. One hundred eighty five medication errors were identified
from 161 patients during the study period. Of this about 67% reach to the patient (but did not cause harm to
the patient) and the rest were intercepted by health professionals before the patient received. Among the
total of ME, one ME was identified in 102 (63.35%) patients, two in 52(32.3) patients and more than 2 MEs
in 7 (4.35%) patients (fig.4)

4%

One
32% Two
More than two
63%

Fig. 4 Number of medication error per patient, Enat Hospital, Ethiopia, 2019

Unnecessary drug therapy was the top ranking medication error (40 % of all MEs) followed by dose to
low(23.5%), need for additional drug therapy (14%), dose to high (12%), product defect (4.3%),
Dilution/reconstitution error(3.2%), ineffective drug therapy(2.6%) and monitoring error(0.4%). The type
and number of medication error identified were characterized as shown in table 2.

Among the total of 185 medication errors detected, majority of errors (52.16%) were due to physicians,
21.89% were due to nurses, 15.27% due to patients and remaining 10.68% were due to pharmacists.
Majority of medication errors committed by physicians attributed causes of these errors were due to lack
of adherence to local/national guidelines and telephone order 35.4% and 16.76% respectively. Patient
non adherence (intentional or unintentional) contributes a lot among errors committed by the
patient.

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 Table 2: Types of medication error, Enat Hospital, Ethiopia, 2019

Type of medication error Number % of errors

Unnecessary drug therapy 74 40

Dose to low 42 23

Need of additional drug therapy 25 14

Dose to high 22 12

Product defect 7 4.3

Dilution/reconstitution error 6 3.2

Ineffective drug therapy 4 2.6

Monitoring error 5 0.4

Drug classes involved in medication error

As indicated in fig. 5 below, anti-infectious agents were the most common drug class involved in MEs
followed by cardiovascular (CV) drugs, gastrointestinal (GI) and anti-asthmatic drugs. Crystalline penicillin,
ceftriaxone, metformin, tramadol and cimetidine were the top ranking drugs involved in ME.

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 30%
25%
20%
15%

Percentages
10%
5%
0%
t sis s a gs gs es
lan ho sic th
m ru ru tiv
gu c la ge s d d fe
c
co
a
ps
y
nti
a GI lar
ti ti An u tii
n
An n A sc An
A va
io
rd
Ca
Drug class

Fig. 5 Drugs involved errors, Alem Ketema, Enat Hospital, Ethiopia

Interventions for drug related problems:

Once identified any medication errors, possible intervention measures were taken to correct the identified
MEs. Interventions were taken after established health care team for the data collection reach in the same
consensus. Data collector team tried to intervene all of detected ME. Majority of interventions were
undertaken by supervisors after informed by data collectors. There are also MEs that were intervened by
physicians/nurses depending on the type of errors and their responsibility after it was notified by data
collectors. The most commonly applied intervention was informing the physicians to discontinue
unnecessary medications:-it could be because of lack of pharmacologic knowledge, to increase the
prescribed drugs, to initiate other medication which is beneficial for the patients, and by providing
appropriate information for dilution/reconstitution of drugs (fig.6).

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 Appropriatley disolve the drug

Types of intervention
Discard the drug

Reduce the dose

Add additional drug/s

Increase the dose

Discontinue medication

0% 5% 10% 15% 20% 25% 30% 35% 40%

% of intervention

Fig. 6 Types of intervention for ME, Alem Ketema Enat Hospital, Ethiopia, 2019

Examples of medication errors identified

Some examples of MEs identified in the study subjects are described in table 3

Table 3: Examples of MEs identified in the study subjects, Alem Ketema Enat Hospital, Ethiopia, 2019

S/ Descriptions of MEs Intervention made

N
1. A 67 years old male patient with history of DM for the last 3 To continue the previous
years and he was on metformin for the last 1 and 6 months since medication after delivering of
diagnosis. But he discontinued for more than 2 months because ample information about negative
he perceive that I feel the best impact of non-adherence.
2. A 54 years old patient admitted with severe community acquired To increase the frequency of
pneumonia from outpatient department. The health care team penicillin: it should be given
decides to initiate treatment of pneumonia and started with every four hours.
penicillin 300,000 iu tid.
3. A 23 years old female known asthmatic patient, presented to To initiate azithromycin for the
hospital with exacerbation increase purulence, cough, increase management of infection.
dyspenia. She is not started antibiotics.
4. 19 years old female patient presented with dysurea, flank pain, To change ceftriaxone to
fever and she is started ceftriaxone. ciprofloxacin because the latter
concentrated more to the urine
and it is better to preserve
ceftriaxone.
5. 53 years old male patient presented with DKA, constipation and Change tramadol to other
pain for the last 2 days and started with management of DKA and NSAIDs because tramadol
constipation: tramadol for pain aggravates constipation.

Predictors of medication error

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 Identification of risk factors for MEs is helpful in finding patients at risk and possible solutions. These
patients can then be given special attention and tray to avoid MEs. Sex, age, availability of drugs, average
number of drugs/day, length of hospital stay and number of co morbidities were analyzed to evaluate
whether they could predict the occurrence of MEs or not. The average number of drugs taken by the
patient/day, co-morbidity, drug availability and hospital stay were shown to be a risk factor for the
occurrence of MEs while age, sex and co-morbidity were not. As shown in table 4, patients who took 1-3
drugs per day were less likely to develop medication error as compared to patients who took more than five
drugs per day. Patients who stayed more than a week per day were more prone to develop medication error
as compared to as compared to those who stayed for less than a week in the hospital. Availability of drugs in
the hospital is also significant predictor for occurrence of medication error in which drug unavailability
prone to patients to have medication errors.
Table 4: Predictors of MEs in the study subjects, Alem Ketema Enat Hospital, Ethiopia, 2019
Variable Category MEs(%) Bivariate analysis Multivariate analysis

Yes No COR(95% CI) P-value AOR(95% CI) P- value

Sex Male 54.5 35. 0.23(0.1-0.51) 0.023 0.74(0.22-12.6) 0.06
0

Female 45.5 65. 1.00 1.00 1.00 1.00

0
Age 19-40 23.3 31.0 0.8(0.32-0.21) 0.045 0.59(0.18-2.00) 0.76
41-59 37.8 40. 0.5(0.21-1.5) 0.05 0.15(0.13-1.92) 0.08
8
60-75 38.9 28. 1.00 1.00 1.00 1.00
2
Co-morbidity Yes 65.2 45. 1.47(0.52-3.64) 0.23 0.32(0.3-1.7) 0.052
2
No 34.8 54. 1.00 1.00 1.00 1.00
8
Length of <1 week 58.3 46. 0.47(0.11-0.55) 0.021 0.21(0.13-0.87) 0.024
Hospital stay
7
≥1 week 41.7 54. 1.00 1.00 1.00 1.00
3
Number of drugs 1-3 26.1 43. 0.65(1.3-10.21) 0.034 0.41(0.3-0.89) 0.025
received/patient
2
3-5 31 38. 0.82(1.23-7.64) 0.054 0.19(0.54-5.4) 0.53
0
≥5 42.9 18. 1.00 1.00 1.00 1.00

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 8
Is/are drug/s Yes 39.5 63. .72(0.68-3.74) 0.054 0.48(0.25-0.87) 0.009
available? 2
No 59.5 37. 1.00 1.00 1.00
8

Discussion

The goal of drug therapy is to achieve defined therapeutic outcomes and improve the patient’s quality of
life while minimizing patient risk. But inappropriate use of drugs during disease management may lead to
drug therapy problems. Identification of MEs and common drugs involved is an important component of
quality drug therapy and contributes to reduction of drug related morbidity and mortality. Majority of
studies conducted at different countries and various groups of patients showed higher prevalence of drug
related problems and indicated different drugs and drug classes involved in ME. This study was carried out
to asses MEs in medical ward in one of a primary care hospital in Ethiopia.
This study showed that 62% of patients admitted to the medical ward within the study period had MEs.
This result is lower than what was found in Jimma, university specialized hospital, Ethiopia (73.5 %) (9).
(11). This lower rate of ME is could be because of number of medication per patient is lower in our study
participants as compared to previous study conducted in Jimma. The study in Malaysia(12) also found a
prevalence of 90.5 %. The lower prevalence of MEs in my study as compared to the Malaysian study might
be because the study was done on specifically patients with type 2 diabetes mellitus and hypertension. These
patients have a higher probability to develop MEs since they prone to receive more drugs and to develop
more complications/drug interactions because of poly pharmacy.
The most frequently encountered MEs in the present study were unnecessary drugs, inappropriate dose,
need of additional drug therapy and product defect. This finding is disagree the study done at US showed
dosing error 175(28%) was among the top ranking types MEs(13) and it is in line with study done in
Indonesia unnecessary drug therapy is the top ranking medication errors(14). In this study more than half of
the patients had faced combination of medication errors/more than one types of errors which is nearly
similar study done in Felege Hiwot Referal Hospital (FHRH(15). The most frequent types of interventions
given by clinical pharmacists were ‘changed drug’, ‘drug stopped’, ‘prescriber informed’, ‘changed
dose’ and ‘drug started’(16). It is in line with our study in which avoiding of unnecessary drugs, to reduce
the dose and addition of other medications.

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 The most frequently prescribed drugs, anti-infective; cardio vascular drugs were and followed by anti-
diabetics drugs. Ceftriaxone, furosemide, spironolactone and metronidazole were the most commonly
prescribed individual drug. Aanti-infectious agents were the most common drug class involved in MEs
followed by cardiovascular (CV) drugs and gastrointestinal (GI) drugs. This may be because of mostly
prescribed drugs. This is nearly similar with the study done in India and Jimma showed that the medication
classes involved most were antimicrobial agents followed by cardiovascular agents(17-18).

In this study medication errors were happened at different stages. Majority of errors (52.16%) were due
to physicians, followed by nurses and pharmacists share the list. Majority medication errors committed
by physicians attributed causes of these errors were due to lack of adherence to local/national guidelines
and telephone order respectively. Patient non adherence (intentional or unintentional)
contributes a lot among errors committed by the patient. This study is disagree with the
previous study done in Washington DC (19). This difference might be because of in our study
almost all of physicians are general practitioner and may not have knowledge about patient
medication reconciliation.

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 Multivariate regression analysis was conducted to identify risk factors for occurrence medication errors.
The result of this study showed that the number of drugs taken by a patient, availability of drugs and
hospital stay are important risk factor for MEs but sex, co-morbidity and age did not have significant
correlation with the occurrence of MEs. Patients who took 1-3 drugs were less likely prone to develop
medication errors as compared to for those who are on more than five drugs. This is supported by a number

of studies(20-23). Medication availability and hospital stay are also significant predictors to develop
medication errors in which the longer hospital stay the more the patient exposed to medication errors. Since
medication errors are a cause for morbidity and mortality hospital pharmacist should continuously evaluate

the availability of drugs in the hospital. However, sex and age were not found to affect MEs (20,21,24). A
study in Singapore similarly showed increasing number of drugs as a risk factor for MEs and the absence of

statistically significant correlation between age and sex with the likelihood of developing MEs (25). In my
study co-morbidity was not found to significantly affect the occurrence of ME. Similarly the study had
found in Jimma did not show significant association between likelihood of MEs occurrence and co-

morbidity (26).

Limitation: our study is single center study and external validity is difficult.

Conclusion
This study revealed that majority of patients exposed to at least one types of medication error.
Unnecessary drug therapy is the most frequently encountered medication error. Ceftriaxone is the top
ranking prescribed drug and medication error happed as well. This study also showed that medication error
happen at different stages and physicians account a lot. Non adherence is one of attributable factor for the
occurrence of medication error committed by the patient. This study showed that there is significant

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association between length of hospital stay, number drugs/patient and availability of drugs and medication
errors.
Abbreviation
ADE: Adverse Drug Event; ADR: Adverse Drug Reaction; MAE: medication administration errors; ME: Medication
error; FHRH: Felege Hiowt Referral Hospital
Ethical considerations: Letter of ethical clearance was secured. Letter for cooperation from department of
internal medicine was obtained. Verbal consent from respective physicians, nurses and patients was secured
to extract data from patents’ medical charts. Participants were also informed that participation was on a
voluntary basis and that they have the right to withdraw at anytime if they are not comfortable with the
study. In order to keep confidentiality, all data were kept anonymously in the observational checklist and
interview questionnaire. Privacy and confidentiality were ensured during patient interview and review of
patient charts.
Consent for publication: not applicable
Availability of data and materials: all data analyzed during this study was available for publication.
Competing interest: The authors declare that they have no competing interests.
Funding: Not applicable
Authors contribution: Conceptualization: Bezie Kebede.
Formal analysis: Bezie Kebede.
Investigation: Bezie Kebede and Yitayih Kefale.
Methodology: Bezie Kebede and Yitayih Kefale.
Writing – original draft: Bezie Kebede.
Writing – review & editing: Bezie kebede and Yitayih Kefale

Acknowledgement: I am very grateful to the nursing staffs for their cooperation for giving sufficient patient
information. I would like to give special thank you for my study participants and data collectors for their
cooperation to participate for this study.

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