Medications Commonly Involved in Medication Errors in Hospital: A Cross-Sectional Survey Study

Ji Min Han; Kyu Nam Heo; Ah Young Lee; Sangil Min; Hyun Jee Kim; Jin-Hee Baek; Juhyun Rho; Sue In Kim; Ji Yeon Kim; Haewon Lee; Eunju Cho; Ju-Yeun Lee; Young-Mi Ah

doi:10.56142/perm.23.0002

Article

original article

Pharmacoepidemiology and Risk Management 2023; 15(1): 72-80

Published online March 31, 2023 https://doi.org/10.56142/perm.23.0002

Medications Commonly Involved in Medication Errors in Hospital: A Cross-Sectional Survey Study

의료기관의 처방오류 및 조제오류 유발 다빈도 약물 분석: 다기관 설문조사 연구

Ji Min Han¹^*, Kyu Nam Heo²^*, Ah Young Lee², Sangil Min^3,4, Hyun Jee Kim⁵, Jin-Hee Baek⁶, Juhyun Rho⁷, Sue In Kim⁸, Ji Yeon Kim⁹, Haewon Lee⁴, Eunju Cho⁴, Ju-Yeun Lee², Young-Mi Ah¹⁰

한지민^1*, 허규남^2*, 이아영², 민상일^3,4, 김현지⁵, 백진희⁶, 노주현⁷, 김수인⁸, 김지연⁹, 이해원⁴, 조은주⁴, 이주연², 아영미¹⁰

Author Info ⁺

¹College of Pharmacy, Chungbuk National University, Cheongju, Korea
²College of Pharmacy, Seoul National University, Seoul, Korea
³Department of Surgery, Seoul National University Hospital, Seoul, Korea
⁴Quality and Patient Safety Center, Seoul National University Hospital, Seoul, Korea
⁵Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
⁶Department of Pharmacy, Seoul National University Hospital, Seoul, Korea
⁷Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
⁸Department of Pharmacy, Chungnam National University Hospital, Daejeon, Korea
⁹Department of Pharmacy, Chungbuk National University Hospital, Cheongju, Korea
¹0College of Pharmacy, Yeungnam University, Gyeongsan, Korea

¹충북대학교 약학대학, ²서울대학교 약학대학, ³서울대학교병원 외과, ⁴서울대학교병원 QPS 센터, ⁵서울대학교병원 지역의약품안전센터, ⁶서울대학교병원 약제부, ⁷분당서울대학교병원 약제부, ⁸충남대학교병원 약제부, ⁹충북대학교병원 약제부, ¹⁰영남대학교 약학대학

Correspondence to:Ju-Yeun Lee
College of Pharmacy, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Korea
Tel: +82-2-3668-7472
Fax: +82-2-874-4169
E-mail: jypharm@snu.ac.kr

Young-Mi Ah
College of Pharmacy, Yeungnam University, 280 Daehak-ro, Gyeongsan 38541, Korea
Tel: +82-53-810-2823
Fax: +82-53-810-4654
E-mail: ymah@ynu.ac.kr

*The first two authors contributed equally to this work.

Received: February 13, 2023; Revised: March 1, 2023; Accepted: March 2, 2023

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Go to

Abstract

Objective: We aimed to identify medications commonly involved in dispensing and prescribing errors in hospitals, using a survey-based approach. Methods: A cross-sectional questionnaire study was conducted by distributing questionnaires to representative pharmacists in charge of medication error reporting in 99 general or higher-level hospitals with 500 beds or more. Results: Out of the 99 hospitals contacted, 38 hospital pharmacy departments (38.4%) responded. Most frequently reported medications involved in dispensing errors were total parenteral nutrition products (23.7% of respondents) followed by morphine (18.4%), lansoprazole (15.8%), and quetiapine (15.8%). Medications commonly involved in prescribing errors that were categorized as extremely or significant important included antineoplastic agents (platinumbased agents, fluorouracil, paclitaxel), systemic anti-infectives (vancomycin, levofloxacin), amiodarone, ketorolac, metoclopramide and dexamethasone. Conclusion: The medications identified in this study as being frequently involved in hospital medication errors can be used as a reference when developing a high-alert medication list for hospitals in the acute care setting.

KeywordsMedication error, High alert medication, Parenteral nutrition, Antineoplastic agents, Anti-infective agents