European Journal of Clinical Pharmacology

, Volume 72, Issue 12, pp 1515–1524 | Cite as

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

  • A. Samsiah
  • Noordin OthmanEmail author
  • Shazia Jamshed
  • Mohamed Azmi Hassali
  • W. M. Wan-Mohaina
Pharmacoepidemiology and Prescription



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.


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


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.


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.


Medication errors Medication error reporting Error reporting system Malaysia 



British National Formulary


Computerised physician order entry


Healthcare provider


Institute for Safe Medication Practices


Look-alike sound-alike


Medication error


Medication Error Reporting System


Ministry of Health Malaysia


National Coordinating Council for Medication Error Reporting and Prevention


National Medical Research Register


National Reporting and Learning System


Pharmaceutical Service Division


Pharmacy Information System


World Health Organization



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.


This research received no funding from any agency.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests.

Supplementary material

228_2016_2126_MOESM1_ESM.docx (21 kb)
ESM 1 (DOCX 21 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • A. Samsiah
    • 1
    • 2
  • Noordin Othman
    • 3
    Email author
  • Shazia Jamshed
    • 1
  • Mohamed Azmi Hassali
    • 4
  • W. M. Wan-Mohaina
    • 5
  1. 1.Kuliyyah of PharmacyInternational Islamic University MalaysiaKuantanMalaysia
  2. 2.Institute for Health Systems ResearchMinistry of HealthShah AlamMalaysia
  3. 3.Department of Clinical and Hospital PharmacyCollege of Pharmacy, Taibah UniversityAlmadinah AlmunawwarahSaudi Arabia
  4. 4.School of Pharmaceutical SciencesUniversiti Sains MalaysiaPenangMalaysia
  5. 5.Pharmaceutical Service DivisionMinistry of HealthPetaling JayaMalaysia

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