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Medication errors reported to the National Medication Error Reporting System in Malaysia: a 4-year retrospective review (2009 to 2012)

  • Pharmacoepidemiology and Prescription
  • Published:
European Journal of Clinical Pharmacology Aims and scope Submit manuscript

Abstract

Purpose

Reporting and analysing the data on medication errors (MEs) is important and contributes to a better understanding of the error-prone environment. This study aims to examine the characteristics of errors submitted to the National Medication Error Reporting System (MERS) in Malaysia.

Methods

A retrospective review of reports received from 1 January 2009 to 31 December 2012 was undertaken. Descriptive statistics method was applied.

Results

A total of 17,357 MEs reported were reviewed. The majority of errors were from public-funded hospitals. Near misses were classified in 86.3 % of the errors. The majority of errors (98.1 %) had no harmful effects on the patients. Prescribing contributed to more than three-quarters of the overall errors (76.1 %). Pharmacists detected and reported the majority of errors (92.1 %). Cases of erroneous dosage or strength of medicine (30.75 %) were the leading type of error, whilst cardiovascular (25.4 %) was the most common category of drug found.

Conclusions

MERS provides rich information on the characteristics of reported MEs. Low contribution to reporting from healthcare facilities other than government hospitals and non-pharmacists requires further investigation. Thus, a feasible approach to promote MERS among healthcare providers in both public and private sectors needs to be formulated and strengthened. Preventive measures to minimise MEs should be directed to improve prescribing competency among the fallible prescribers identified.

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Abbreviations

BNF:

British National Formulary

CPOE:

Computerised physician order entry

HCP:

Healthcare provider

ISMP:

Institute for Safe Medication Practices

LASA:

Look-alike sound-alike

ME:

Medication error

MERS:

Medication Error Reporting System

MOH:

Ministry of Health Malaysia

NCCMERP:

National Coordinating Council for Medication Error Reporting and Prevention

NMRR:

National Medical Research Register

NRLS:

National Reporting and Learning System

PSD:

Pharmaceutical Service Division

PhIS:

Pharmacy Information System

WHO:

World Health Organization

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Acknowledgments

We would like to thank the Director-General of Health Malaysia for the permission to publish this work. We would also wish to express our gratitude to the PSD, MOH Malaysia for the approval to use the available data for this project and the staff of the Medication Safety Unit for their assistance and supervision in the data collection process and providing necessary information on the improvement strategies.

Contribution of authors statement

This paper is part of SA’s Ph.D endeavour. The research was conducted by SA and supervised by NO, SJ and MAH. WMWM assisted and supervised in the data collection process. SA analysed the data and prepared the first draft of the manuscript. All authors were responsible for the critical revision of the manuscript and approved the submission of the final manuscript.

Funding

This research received no funding from any agency.

Author information

Authors and Affiliations

  1. Kuliyyah of Pharmacy, International Islamic University Malaysia, 25200, Kuantan, Pahang, Malaysia

    A. Samsiah & Shazia Jamshed

  2. Institute for Health Systems Research, Ministry of Health, 40170, Shah Alam, Selangor, Malaysia

    A. Samsiah

  3. Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Almadinah Almunawwarah, Saudi Arabia

    Noordin Othman

  4. School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Penang, Malaysia

    Mohamed Azmi Hassali

  5. Pharmaceutical Service Division, Ministry of Health, Petaling Jaya, 46350, Petaling Jaya, Selangor, Malaysia

    W. M. Wan-Mohaina

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  1. A. Samsiah
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  2. Noordin Othman
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Correspondence to Noordin Othman.

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Samsiah, A., Othman, N., Jamshed, S. et al. Medication errors reported to the National Medication Error Reporting System in Malaysia: a 4-year retrospective review (2009 to 2012). Eur J Clin Pharmacol 72, 1515–1524 (2016). https://doi.org/10.1007/s00228-016-2126-x

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