Contributing factors to outpatient pharmacy near miss errors: a Malaysian prospective multi-center study
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Background Detecting errors before medication dispensed or ‘near misses’ is a crucial step to combat the incidence of dispensing error. Despite this, no published evidence available in Malaysia relating to these issues. Objective To determine the incidence of medication labeling and filling errors, frequency of each type of the errors and frequency of the contributing factors at the final stage before dispensing. Setting Six Penang public funded hospitals outpatient pharmacies. Methods A prospective multicentre study, over 8 week’s period. Pharmacists identified and recorded the details of either medication labeling and/or filling error at the final stage of counter-checking before dispensing. Besides, the contributing factors for each error were determined and recorded in data collection form. Descriptive analysis was used to explain the study data. Main outcome measure The incidence of near misses. Results A total of 187 errors (near misses) detected, with 59.4% (n = 111) were medication filling errors and 40.6% (n = 76) were labeling errors. Wrong drug (n = 44, 39.6%) was identified as the highest type of filling errors while incorrect dose (n = 34, 44.7%) was identified as the highest type of labeling errors. Distracted and interrupted work environment was reported to lead the highest labeling and filling errors, followed by lack of knowledge and skills for filling errors and high workload for labeling errors. Conclusion The occurrence of near misses related to medication filling and labelling errors is substantial at outpatient pharmacy in Penang public funded hospitals. Further research is warranted to evaluate the intervention strategies needed to reduce the near misses.
KeywordsContributing factors Filling Labeling Malaysia Medication Medication errors Near misses
We would like to thank the Director of Health Malaysia for permission to publish this research. We also would like to extend our heartiest appreciation to Director of Pharmacy (Penang), Pn.Zubaidah Che Embi and the head of the pharmacy of all the public-funded hospitals involved for their cooperation. Further, we want to acknowledge all the data collectors and staffs of the outpatient pharmacy.
The authors received no financial support for the research, authorship, and/or publication of this article.
Conflicts of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
- 6.Abdullah DC, Ibrahim NS, Ibrahim MIM. Medication errors among geriatrics at the outpatient pharmacy in a teaching hospital in Kelantan. Malays J Med Sci. 2004;11(2):52–8.Google Scholar
- 7.Kuan MN, Chua SS, Ramli MN. Noncompliance with prescription writing requirements and prescribing errors in an outpatient department. Malays J Pharm. 2002;1(2):45–50.Google Scholar
- 8.Norsa’adah B, Norbanee THT, Zaliha I, Wil AC. Prescription writing errors by doctors at Pasir Mas Hospital. Int J Med. 2006;13(1):15–8.Google Scholar
- 9.Chua SS, Kuan MN, Ramli MN. Outpatient prescription intervention activities by pharmacists in a teaching hospital. Malays J Pharm. 2003;1(3):86–90.Google Scholar
- 10.Hassan H, Das S, Se H, Damika K, Letchimi S, Mat S, et al. A study on nurses’ perception on the medication error at one of the hospitals in East Malaysia. Clin Ter. 2009;160(6):477–9.Google Scholar
- 12.Ong WM, Subasyini S. Medication errors in intravenous drug preparation and administration. Med J Malays. 2013;68(1):52–7.Google Scholar
- 22.Guide on handling look alike, sound alike medications, first edition, Pharmaceutical Service Divison, Ministry of Health Malaysia; 2012.Google Scholar
- 25.Pharmaceutical Services Division Penang State Health Department. Good Prescribing Guideline; 2014.Google Scholar