Indian Journal of Pharmacy and Pharmacology

Page: 240-245

Background: To evaluate the prevalence, types, severity, and contributing factors of medication errors (MEs) in a tertiary and quaternary care hospital over a four-year period, and to assess the impact of clinical pharmacists in identifying and reducing these errors.

Aim & Objective: To assess the prevalence, types, severity, and contributing factors of medication errors in a tertiary care hospital over a four-year period, and to evaluate the role of clinical pharmacists in identifying and reducing errors.

Materials and Methods: A retrospective observational study was conducted from January 2020 to December 2023 in a tertiary care hospital with 800-bed capacity. A total of 42,729 prescription charts from inpatient and critical care departments were analysed. Medication errors were identified through a hospital intranet reporting system and categorized by clinical pharmacists using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) classification.

Results: A total of 551 medication errors were recorded. The majority were of mild severity (NCC MERP categories B and C), with a marked decline in error frequency over the study period. Critical care units reported 174 errors, primarily administration errors, while 377 errors were from inpatient units, with transcription errors being the most frequent in 2020. Only one severe error (Category G) was identified. Contributing factors included insufficient training, misinterpretation of dosing schedules, and lack of knowledge. The clinical pharmacists played a key role in identifying, reporting, and reducing errors through audits and staff education.

Conclusion: The study demonstrates a declining trend in medication errors over four years, largely attributed to the proactive involvement of clinical pharmacists. Most errors did not result in patient harm. Continuous training, system-level interventions, and enhanced pharmacist involvement are essential to further improve patient safety and healthcare quality.