See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/299468721

A Study of medication administration errors in a tertiary care hospital

Article  in  INDIAN JOURNAL OF PHARMACY PRACTICE · April 2011

CITATIONS READS

16 91

3 authors, including:

Ramesh Adepu Venkateswarlu Konuru

Vikas College of Pharmaceutical Sciences, Rayanigudem, Suryapeta, Telengana St… CMR College of Pharmacy, Hyderabad , India
36 PUBLICATIONS   481 CITATIONS    31 PUBLICATIONS   96 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Evaluation of Pharmacoecoonomic direct cost in Diabetes Patients View project

Case Report Full Proceeding Paper NEVIRAPINE INDUCED MACULOPAPULAR RASH View project

All content following this page was uploaded by Venkateswarlu Konuru on 02 January 2017.

The user has requested enhancement of the downloaded file.

 Indian Journal of Pharmacy Practice Association of Pharmaceutical Teachers of India

A Study of medication administration errors in a tertiary care hospital

Arun Kumar K.S, Venkateswarlu K, Ramesh A*,
Department of Pharmacy Practice, JSS College of Pharmacy, JSS Univeristy SS Nagar, Mysore, Karnataka, India.

ABSTRACT Submitted: 23/2/2011 Accepted: 25/3/2011

Medication administration errors account for 34% of all medication errors and identified as one of the important reasons for patients' morbidity
and mortality. NPSA statistics show that 59.3% of medication errors occur during the administration stage. Thus identifying and resolving the
administration errors will improve the patient care and decreases the health care costs. National Coordinating Council for Medication Error
Reporting and Prevention (NCC MERP) taxonomy was used to analyse the frequency, types, severity and factors responsible for medication
administration errors. The findings of the study reveal that the frequency of medication administration errors is 15.34%, omission errors
(33.02%), improper dose (17.43%) and wrong time (12.84%) errors were the major types of errors occurred and the majority administration
errors belonged to categoty C (112), B (46) and D (35). Frequent interruptions and distractions, lack of communication between health care
professionals, performance deficit and work stress on duty nurses are identified as major factors responsible for administration errors.
Keywords: Medication Administration Errors (MAEs), National Coordinating Council for Medication Error Reporting (NCC MERP) taxonomy,
National Patient Safety Agency (NPSA) and Patient Care.

INTRODUCTION unintentionally.2 The elderly, and mentally ill patients are

particularly more susceptible as they may be confused, resist
Medication use in hospitals is a complex process and depends
on successful interaction among health care professionals medication administration, physically weak and require
functioning at different areas. Medication errors may occur at complex medication regimens.5 In a study conducted over a
any stage of prescribing, documenting, dispensing, period of three and half years in UK at a psychiatric hospital,
preparation, or administeration.1 Medication errors may the most frequent types of errors observed were the improper
contribute to morbidity, mortality and increased health care dose, wrong drug, and dose omission.6 The drugs often
costs. In 2007, National Patient Safety Agency (NPSA)
2
associated with harmful events of medication errors in
statistics shows that 59.3% of medication errors occur during pediatric patients include morphine, insulin, vancomycin,
potassium chloride, gentamicin, ceftriaxone, and heparin.
4
the administration stage.3 Medication administration errors
are defined as any deviation from the physician's medication
In addition to the morbidity and mortality, medication errors
order as written on patient's treatment chart during medication
also contribute to increased health care costs. The department
administration to patient.2 The plan for administering a
of health in UK, estimated the direct and indirect health care
medication begins with identifying the patient, the drug, the
expenditure due to medication errors as 2£ billion.1 In US, an
dose, the route, and the time.4 In 1995, the National
American health care system estimated the medication errors
Coordinating Council for Medication Error Reporting and
related expenditure as $37 billion per year.
7

Prevention (NCC MERP) classified administration errors in

to wrong drug, wrong route, wrong dose, wrong patient, Medication administration has become more complex as a
wrong timing of drug administration, contra-indicated drug, result of the increasing number of medications available and
wrong site, wrong dosage form, wrong infusion rate and new routes of administration. Nurse is considered as vital in
expired medication. Such errors may occur intentionally or medication administration process and the literature review
Address for Correspondence:
states that poor calculation competency of nurses, poor
Dr. Ramesh Adepu, Professor, Department of Pharmacy Practice, JSS College of adherence to protocols and poor knowledge of medications
Pharmacy, JSS University, SS Nagar, Mysore -15 are the important reasons leading to medication
E-Mail: [email protected]
administration errors.4

Indian Journal of Pharmacy Practice Volume 4 Issue 2 Apr - Jun, 2011 37

 Ramesh A - A Study of Medication Administration Errors in a Tertiary Care Hospital

An observational research study conducted in Newzealand of medication administration errors was analysed by using the
conclude that, poor knowledge of nurses about medicines, following formula.10
dose calculations, and route of administration were the key Number of Significant + Non significant MAEs
elements contributing for medication administration errors.
2 Frequency of MAE = -------------------------------------------------------- X 100
Doses given + doses ordered but not given
The other contributing factors for MAE were identified as
frequent distractions from work, peak work load, and NCC MERP taxonomy was applied to analyse the frequency
and types of medication administration errors. The types of
inadequate communication between health care
medication administration errors were classified in to
professionals. An observational multinational study
omission error, improper dose, wrong medication, wrong
conducted in 27 countries of five continents by Valentin A et al
strength, wrong dosage form, wrong technique, wrong route
suggest that, increased work load, stress, and fatigue are the
of administration, wrong rate, wrong time, wrong patient
contributing factors for medication administration errors. In
errors and other types. 11
addition to the above, poor hand writing in prescriptions,
drugs with similar packing are the system errors leading to Medication administration errors were categorised in to
medication administration errors. Therefore medication
8 various categories as A, B, C, D, E, F, G, H and I categories
errors may compromise patient confidence in the health-care based on NCC MERP. Current NCC MERP categorizes
system.9 Worldwide intensive research was conducted to find medication administration errors in to the 9 following
categories.
the types, categories, contributing factors, and cost
implications of medication administration errors in various Category A: Circumstances or events that have the capacity
health care settings however very little research was to cause an error
conducted in this area in India. Thus the present study was Category B: An error has occurred but the error did not reach
conducted to assess the frequency, types, severity and factors the patient
responsible for medication administration errors in a tertiary
Category C: An error has occurred that reached the patient,
care teaching hospital.
but did not cause harm to patient
MATERIALS AND METHODS
Category D: An error has occurred that reached the patient
Study Setting and required monitoring to confirm that it resulted in no harm
to the patient and/or required intervention to preclude harm.
The present study was conducted at a South Indian 1200 bed
multi specialty tertiary care teaching hospital for a period of Category E: An error has occurred that may have contributed
nine months during November 2009 and August 2010 in to or resulted in temporary harm the patient and required
inpatient wards of general medicine and surgery departments. intervention
Every day 200 patients are admitted either from the Category F: An error has occurred that may have contributed
outpatient, emergency and casualty departments or to or resulted in temporary harm to the patient and required
transferred from the wards of other clinical specialties to the initial or prolonged hospitalization
above departments. The present study was approved by the
Category G: An error has occurred that may have contributed
Institutional Human Ethics Committee.
to or resulted in permanent patient harm
Study procedure
Category H: An error has occurred that required intervention
A suitably designed documentation form was used to analyse necessary to sustain life
the types, frequency and factors responsible for medication
Category I: An error has occurred that may have contributed
administration errors and the data was collected from the case to or resulted in the patient's death.
notes, treatment charts, medication administration records
and interviewing the in-patients admitted to surgery and RESULTS
general medicine wards. Demographic details of the patients, Medication records of 286 patients were reviewed and 218
diagnosis and treatment recommended were documented. medication administration errors were observed in 167
Medication administration of the in-patients was followed up patients who received 1430 doses. The frequency rate of
on daily basis to identify the administration errors. Frequency medication administration errors was found as 15.24%.

Indian Journal of Pharmacy Practice Volume 4 Issue 2 Apr - Jun, 2011 38

 Ramesh A - A Study of Medication Administration Errors in a Tertiary Care Hospital

Among the 167 patients, 115 were male patients and 52 were The system related factors responsible for medication
female patients. Out of 218 medication administration errors, administration errors identified as prequent interruptions and
112 errors (51.37%) were observed in surgery department and distractions (33%), poor communication among health care
106 errors (48.62%) were observed in medicine department. professionals (23%), inadequate training (8%) and
According to the NCC MERP taxonomy, the medication inadequate staff (8%) and others (14%). The details of factors
administration error types were analysed. The most common responsible for MAE are presented in Table No 2.
types of errors observed were omission errors (failure to Human factors responsible for medication administration
administer or failure to record the administration, (n=72) and errors were studied. Predominant human factors responsible
improper dose (over dosage (n=38), followed by wrong time for MAE were identified as performance deficit (42.20%),
(n=28), wrong strength (e.g. dose was given in noon instead of stress (21.10%) and fatigue and lack of sleep (8.71%) and the
morning dose (n=21), wrong rate ( IV infusion rate was too list of human contributing factors causing medication
fast, ( n=18), wrong drug (drug other than the prescribed one, administration errors are presented in Table No 3. Types of
(n=12), and others (Patients refusal to take medication/not dosage forms highly involved in medication administration
bought the medication, (n=14). The details of types of errors were injectable drugs (49.54%) and tablets (33.94%).
medication administration errors are given in Table No 1. The types of dosage forms involved in MAE are presented in
Table 1: Types of Medication Administration Errors Fig. 2.
S.No Types of errors Percentage (%)
1. Omission error 33.02 Table 2: System related factors responsible for MAEs
2. Improper dose/quantity 17.43 Sl. No. Contributing factors Percentage (%)
3. Wrong strength 09.63 1 Lack of Lighting 6.0
4. Wrong drug 05.50 2 High Noise level 8.0
5. Wrong dosage form 01.83 3 Frequent interruptions 33.0
6. Wrong route 01.83 & distractions
7. Wrong rate: too fast 08.25 4 Lack of training 8.0
8. Wrong duration 03.21 5 Lack of staffing 8.0
9. Wrong time 12.84 6 Lack of Communication 23.0
10. Others 06.42 between HCPs
Note: Others include (Patient refusal to take medication/ Unable to 7 Others* 14.0
purchase/swallow medication etc) *Others = Patient refusal to take medication/ Unable to
purchase/swallow medication etc
Majority administration errors were belonged to the Category
C (52.75%), Category B (21.10%) and Category D (16.05%)
Table 3: Human Factors responsible for MAEs
followed by the category E; (07.79) and category F; (02.29).
S.No Human factors Percentage (%)
Details of categories of the medication administration errors 1 Knowledge deficit 05.50
according NCC MERP categorisation are presented in Fig. 1. 2 Performance deficit 42.20
3 Miscalculation of dosage 05.96
Fig. 1: NCCMERP Categorization of MAEs or infusion rate
4 Stress 21.10
5 Fatigue/ lack of sleep 08.71
6 Poor communication among 01.83
health care professionals
7 Others* 14.67
* Others include (Patient refusal to take medication/ Unable to
purchase/swallow medication etc).

Axis X: Type of Category, Y Axis: Number of Medication

Administration Errors

Indian Journal of Pharmacy Practice Volume 4 Issue 2 Apr - Jun, 2011 39

 Ramesh A - A Study of Medication Administration Errors in a Tertiary Care Hospital

Fig. 2: Type of Dosage forms Involved in MAEs As medication errors are resulting in damage to patient's
health and influence the health care budgets, it is worth
studying the types, frequency, impact of medication errors
and the factors responsible for administration errors. The
literature review suggests limited research has been carried
out in India in this area. The present study focuses on
scientific understanding the medication administrations
errors in a tertiary care teaching hospital and to suggest
initiatives to improve the patient safety.
During the study period, frequency of medication
administration errors was calculated as 15.24%. In many
DISCUSSION
overseas studies, the frequency of medication administration
Medication use is a complex process that involves co- errors range from 14 to 59%. In two observational studies
ordination among various health care professionals. conducted in an acute settings have found the medication
Medication errors may happen at any stage of patient care like administration error frequency rates as 14.9% and 32.4%.2 In
prescribing, transcribing, dispensing, and administration.
1
a prospective cohort study, the frequency of medication
Studies have corroborated that medication administration administration errors was found as 38%. Analysis of
errors may contribute to morbidity, mortality and increased MEDMARX data base suggests the frequency of medication
health care expenditures. 1,7 A study has calculated a administration errors as 59.5%. The error frequency rate in
medication error cost as USD 5000. 12 Medication the present study closely matches with the findings of the
administration errors may take place at the time of international studies. The higher the frequency of medication
administration due to prescriber's medication order deviation. administration errors occur results in higher chances of
As per National Health Service (NHS) of UK statistics, morbidity and mortality in the patients.
medication errors may affect 850,000 people each year and
incurr the health care expenditure up to £2 billion.1 In USA, NCC MERP taxonomy was used to analyse the categories of
American Health System calculated the morbidity, mortality the medication administration errors. The medication
and health care expenditure associated with medication administration errors of the present findings were analyzed
errors. The statistics reveal that medication errors had caused and classified in to various categories. In our study the most
88,000 deaths and incurred $37 billion as health care common types of errors observed were omission errors
expenditure annually.7 In a US based study, it was estimated (failure to administer or failure to record the administration,
that medication administration errors have accounted for 34% n=72) and improper dose (over dosage, n=38), followed by
of medication errors.5 National Patient Safety Agency wrong time (n=28), wrong strength (e.g. dose was given in
(NPSA) shows that 59.3% of medication errors occur at noon instead of morning dose. n=21), wrong rate ( IV infusion
administration stage having high potential for morbidity and rate was too fast, n=18), wrong drug (drug other than the
mortality and increased health care costs.3 Adminstration prescribed one, n=12), and others (Patients refusal to take
errors are one of the most common types of medication errors medication/not bought the medication, n=14). Our
affecting approximately 5 percent of all administered doses. 6 observations are in consistent with the findings of previous
studies.8
In the health care team, nurse is responsible for medication
administration to the patients and is there fore considered as In a prospective observational multinational study involving
the key faulty component for medication administration 113 ICUs from 27 countries across five continents, including
errors. The findings of many international studies showed
3
Australia the most common adminstration errors include
that, performance deficit, poor calculation competency, poor wrong time of administration (n = 386), missed medication (n
adherence to protocols, poor knowledge of medications and = 259), followed by wrong dose (n = 118), wrong drug (n =
61) and wrong route (n = 37). Similarly in another
8
complacent behaviour of the nurses are the main reasons for
medication administration errors.13 Other system related observational study of MAEs conducted by Camilla Haw
causes for administration errors include physicians poor hand et.al. in old-age psychiatric inpatient wards at St. Andrew's
writing, similar packing of medications. Hospital, UK identified 148 administration errors through

Indian Journal of Pharmacy Practice Volume 4 Issue 2 Apr - Jun, 2011 40

 Ramesh A - A Study of Medication Administration Errors in a Tertiary Care Hospital

treatment chart review. The most common types of errors administration (43.4%), followed by wrong infusion rate
detected were belong to omissions errors (133), Improper (23%).13 The increased frequency of the medication
dose errors (over doses, 9), wrong time errors (5) and administration errors is may be due to various contributing
administration of a discontinued medication (1). The MAEs factors. The findings of our study were also similar to that of
detected were reported using hospital's medication error the findings of Tehran study.
reporting system.
5
Adequate training and motivation to nurses, computerized
In the present study NCC MERP taxonomy was used to assess physician order entry system (CPOE) and medication
the severity of the medication administration errors on patient administration record system will help in preventing the
outcomes. As per the taxonomy, Category A to D is medication administration errors by nurse. Introduction of
considered as mild, E and F is moderate and G to I is severe in Medication Error reporting system in the hospital will help in
nature. The medication administration errors were analyzed preventing the medication errors.
and classified in to various categories. Most of the errors were CONCLUSION
belonged to the Category C (52.75%), Category B (21.10%)
and Category D (16.05%) followed by the category E; (07.79) The findings of the present study concludes that, omission of
and category F; (02.29). In a descriptive and retrospective the dose, improper dose, wrong time, and wrong strength
study conducted over a period of 5 years to assess the were identified as common medication administration errors.
administration errors made by nursing students, categorized Majority errors belong to NCCMERP category C and
the medication administration errors using NCC MERP interruption and distractions during the work, performances
taxonomy. Most of the administration errors belonged to the deficit, and stress are the common risk factors contributing for
medication administration errors.
Category C (70.57%) and Category D (23.29%).
13

Frequent interruptions and distractions (32.56%), lack of ACKNOWLEDGEMENTS

communication between the health care professionals (HCPs) We extend our sincere thanks to JSS University, Dr.
(23.39%), other factors (13.76%), lack of staffing and noise H.G.Shivakumar, Principal, JSS College of Pharmacy, Dr. G.
level (08.25%) and lack of training (7.79%) are identified as Parthsarathi, Head, Department of Pharmacy Practice, Dr.
the system related factors responsible for medication K.A.S Murthy, Head, Department of Medicine, Dr. Siddesh,
administration errors in our study. Head, Department of Surgery, JSS Medical College and
Hospital, Mysore for their support in carrying out the research
An observational multinational study identified heavy
work.
workload, stress and fatigue are the contributing factors
causing 32% (n = 272) of the administration errors followed REFERENCES
by lack of knowledge (n = 81, 9%), violation in protocols (n =
1. Rhonda L, Neville A.S, David H. Applying hierarchical
76, 9%) and problems with handover processes (n = 53, 65).
8

task analysis to medication administration errors.

Zane Robinson et al, in their study identified performance Applied Ergonomics 2006; 37:669–79.
deficit (51.01%) and knowledge deficit (26.52%) as the
2. Karen M and Maralyn F. Medication Administration
common contributing factors responsible for medication
Errors: Understanding the Issues. Ajan 2006 May;
administration errors. The common human factors
23(3):33-41.
responsible for medication administration errors were also
studied. They were identified as performance deficit 3. Jones SW. Reducing medication administration errors in
(42.20%), stress (high work load etc) (21.10%), others nursing practice. Nursing Standard 2009;23(50):40-46.
(14.67%), and fatigue (08.71%) are the commonest human 4. Susan P. Beyond the Five Rights: Improving Patient
factors responsible for medication administration errors.12 Safety in Pediatric Medication Administration through
In our study, the dosage forms which are involved in most Simulation. Clinical Simulation in Nursing 2009;5:181-
86.
MAEs include injectable drugs (49.54%) and tablets
(33.94%). In a study conducted by Fanak Fahimi et al. in ICU 5. Camilla H, Jean S, Geoff D. An observational study of
and medical wards of a large hospital in Tehran observed that medication administration errors in old-age psychiatric
the majority of administration errors occurred during bolus inpatients. Int qhc 2007;19(4):210–16.

Indian Journal of Pharmacy Practice Volume 4 Issue 2 Apr - Jun, 2011 41

 Ramesh A - A Study of Medication Administration Errors in a Tertiary Care Hospital

6. Camilla H, Jean S, Geoff D. A Review of Medication 11. The National Coordinating Council for Medication
Administration Errors Reported in a Large Psychiatric Error Reporting and Prevention. 2005 Dec.
Hospital in the United Kingdom. Psychiatric Services http://www.nccmerp.org (Accessed on 08/Nov/2010).
2005;56(12):1610-13. 12. Zane R W, Rodney H, Joanne F S. Characteristics of
7. James H P, Ilan S R. Medical errors education for Medication errors made by students during the
students of surgery: A pilot study revealing the need for administration phase: A descriptive study. J Prof Nurs
action. Journal of surgical education 2009; 66(1):20-24. 2006;22:39-51.

8. Elizabeth Manias RN. Errors in administration of 13. Fanak F, Parham A, Mehrdad F, Rocsanna N, Maria T A.
parenteral medications are a serious safety problem in Errors in preparation and administration of intravenous
intensive care units. Australian College of Critical Care medications in the intensive care unit of a teaching
Nurses 2009 4;22:141-3. hospital: An observational study. Australian College of
Critical Care Nurses 2008;21:110-16.
9. American Society of Hospital Pharmacists (ASHP).
Guidelines on Preventing Medication Errors in 14. Marie C B, Sylvia P, Francois E A, Jean-J M, Michel D,
Hospitals. American Journal of Hospital Pharmacy. Patrice D. Impact of CPOE on doctor—nurse
1993;50:305–14. cooperation for the medication ordering and
administration process. International journal of medical
10. Barbara S C. The regulatory influence on medication
informatics 2005;74:629-41.
administration in long-term care facilities. Geriatric
Nursing; 26(4):212-215.

Indian Journal of Pharmacy Practice Volume 4 Issue 2 Apr - Jun, 2011 42

View publication stats