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Medication Error Reporting in a University Teaching Hospital in Saudi Arabia

Alshaikh, Mashael B Pharm, BCPS*†; Mayet, Ahmed PharmD, BCPS†‡; Aljadhey, Hisham PharmD, PhD†‡

doi: 10.1097/PTS.0b013e3182845044
Original Articles

Objectives Medication errors are common in the hospital setting. Little is known about these errors in Saudi Arabia. The objective of the current study was to explore the rate of reporting medication errors and factors associated with the root causes of these errors in a large tertiary teaching hospital in Saudi Arabia.

Methods This study was conducted at the university teaching hospital in Riyadh, Saudi Arabia. All occurrence/variant reports related to medication errors were documented on a hospital Web-based medication error form that was designed to capture information on all aspects. Medication error reports were reviewed and reported at quarterly intervals over a 1-year period (November 2009 to October 2010).

Results The medication error rate over the 1-year study period was 0.4% (949 medication errors for 240,000 prescriptions). During this period, 14 (1.5%) errors were categorized as resulting in any harm to the patient (all category E). Medication errors were reported predominantly at the prescribing stage of the medication process (89%). The most common types of errors were prescribing (44%) and improper dose/quantity (31%). Antibiotics (12%), antihypertensive agents (10%), and oral hypoglycemic agents (8%) were the pharmacological classes of medication most commonly involved with errors. Nonspecific performance deficit (43%), knowledge deficit (28%), and illegible or unclear handwriting (17%) were the main reported causes of error.

Conclusions Medication errors are underreported in a tertiary teaching hospital in Riyadh, Saudi Arabia. Future studies should evaluate the effectiveness of interventions to stimulate medication errors reporting by health-care providers.

From the *Pharmacy Services Department, King Khalid University Hospital; †Medication Safety Research Chair and ‡Clinical Pharmacy Department, of the College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.

Correspondence: Ahmed Mayet, PharmD, BCPS, Pharmacy Services Department (18), King Khalid University Hospital, P.O. Box 11472, Riyadh, Saudi Arabia (e-mail:

Conflicts of interest and source of funding: The authors declare no conflicts of interest. Technical support for the study was received from the Medication Safety Research Chair at King Saud University and the National Plan for Science and Technology (09-bio708-02).

© 2013 by Lippincott Williams & Wilkins