Pharmacy-Based Evaluation of Near-Miss Medication Errors in Teaching Hospitals

Year 2025, Volume: 55 Issue: 3, 470 - 479, 14.01.2026

Norkasihan Ibrahim , Shamala Balan , Yogini Jani , Noraiza Abdul Rahman , Ainul Mawaddah Suhaime Affindi Mohammad Azızul Mohd Latıp Muhammad Asyraf Harun

https://doi.org/10.26650/IstanbulJPharm.2025.1640916

https://izlik.org/JA64GR29MW

Abstract

Background and Aims: The progression of near-miss medication errors may lead to patient harm and legal implications. The magnitude and characteristics of near-miss medication errors in teaching hospitals are poorly understood. This study aimed to analyse near-miss medication errors at two teaching hospitals.

Methods: Medication errors reported in year 2022 were retrieved from the hospital database and screened to collect data on the types of error, medications involved, and contributing factors for near-miss prescribing error (NMPE) and near-miss dispensing error (NMDE) from the outpatient (OPD) and inpatient (IPD) pharmacy departments. Descriptive and chi-square (χ2) analyses were conducted to evaluate NMPE and NMDE by settings.

Results: Of the 4657 reports, 3148 (67.6%) and 1509 (32.4%) were NMPE and NMDE, respectively. OPD had a higher rate of NMPE (1.76%, 95% CI 1.69–1.83%) than IPD (1.0%, 95% CI 0.78–1.16%). The rate of NMDE in the IPD was threefold as compared to that in the OPD [1.28% (1.21–1.35%) vs. 0.38% (0.28–0.32%)]. The medications from the alimentary tract and metabolism group (n = 936/4644, 20.16%) were commonly involved in nearmiss medication errors. The primary contributing factor was confusion with the electronic prescribing system (511/2022, 25.27%). Near misses of inappropriate regimens were more likely in OPD (χ2(2) = 14.7, p<0.001). Near misses of labelling were more likely in the IPD (χ2(1) = 7.5, p<0.001).

Conclusion: Near-miss medication errors were prevalent, with distinct patterns observed in outpatient and inpatient settings.. Strengthening electronic prescribing processes and reducing system-related confusion may enhance medication safety in teaching hospitals.

Keywords

Medication Errors , Prescription Errors , Patient Safety , Teaching Hospitals

References

• Abdel-Qader, D. H., Al Meslamani, A. Z., Lewis, P. J., & Hamadi, S. (2021). Incidence, nature, severity, and causes of dispensing errors in community pharmacies in Jordan. International Journal of Clinical Pharmacy, 43, 165–173. https://doi. org/10.1007/s11096-020-01126-w google scholar
• Al-Dhawailie, A. A. (2011). Inpatient prescribing errors and pharmacist intervention at a teaching hospital in Saudi Arabia. Saudi Pharmaceutical Journal, 19(3), 193– 196. https://doi.org/10.1016/j.jsps.2011.03.001 google scholar
• Aldhwaihi, K., Schifano, F., Pezzolesi, C., & Umaru, N. (2016). A systematic review of the nature of dispensing errors in hospital pharmacies. Integrated Pharmacy Research and Practice, 5, 1–10. https://doi.org/10.2147/IPRP.S95733 google scholar
• Alshaikh, M., Mayet, A., & Aljadhey, H. (2013). Medication error reporting in a university teaching hospital in Saudi Arabia. Journal of Patient Safety, 9(3), 145–149. https://doi.org/10.1097/PTS.0b013e3182845044 google scholar
• Al-Zaagi, I. A., Khalid, A. A., Al-Dossari, D. S., Salem, S. O., & Qureshi, N. A. (2013). Analysis of reported e-prescribing near misses in King Saud Medical City, Riyadh. Integrated Pharmacy Research and Practice, 2, 17–24. https://doi.org/ 10.2147/IPRP.S52080 google scholar
• Azmi, A. (2021). Norchaya Talib on torts in Malaysia. Sweet & Maxwell. google scholar
• Baysari, M. T., & Raban, M. Z. (2019). The safety of computerised prescribing in hospitals. Australian Prescriber, 42(4), 136–138. https://doi.org/10.18773/austprescr. 2019.037 google scholar
• Cerqueira, O., Gill, M., Swar, B., Prentice, K. A., Gwin, S., & Beasley, B. W. (2021). The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour & improve safety. BMJ Quality & Safety, 30(12), 1038–1046. https://doi.org/10.1136/bmjqs-2020-012283 google scholar
• Chu, A., Kumar, A., Depoorter, G., Franklin, B. D., & McLeod, M. (2022). Learning from electronic prescribing errors: a mixed methods study of junior doctors’ perceptions of training and individualised feedback data. BMJ Open, 12(12), e056221. https://doi.org/10.1136/bmjopen-2021-056221 google scholar
• Cuevas, C., Batura, N., Wulandari, L. P. L., Khan, M., & Wiseman, V. (2021). Improving antibiotic use through behaviour change: a systematic review of interventions evaluated in low-and middle-income countries. Health Policy and Planning, 36(5), 594–605. https://doi.org/10.1093/heapol/czab021 google scholar
• Devin, J., Cullinan, S., Looi, C., & Cleary, B. J. (2022). Identification of prescribing errors in an electronic health record using a retract-and-reorder tool: a pilot study. Journal of Patient Safety, 18(7), e1076–e1082. https://doi.org/10.1097/PTS. 0000000000001011 google scholar
• Elliott, R. A., Camacho, E., Jankovic, D., Sculpher, M. J., & Faria, R. (2021). Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Quality & Safety, 30(2), 96–105. https://doi.org/10.1136/ bmjqs-2019-010206 google scholar
• Elshayib, M., & Pawola, L. (2020). Computerized provider order entry–related medication errors among hospitalized patients: an integrative review. Health Infor^ matics Journal, 26(4), 2834–2859. https://doi.org/10.1177/1460458220941750 google scholar
• Hareem, A., Lee, J., Stupans, I., Park, J. S., & Wang, K. (2023). Benefits and barriers associated with e-prescribing in community pharmacy–a systematic review. Exploratory Research in Clinical and Social Pharmacy, 12, 100375. https://doi. org/10.1016/j.rcsop.2023.100375 google scholar
• Hussain, M. I., Reynolds, T. L., & Zheng, K. (2019). Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review. Journal of the American Medical Informatics Association, 26(10), 1141– 1149. https://doi.org/10.1093/jamia/ocz095 google scholar
• Jahn Kassim, P. N. (2021). Medical negligence in Malaysia: cases and commentary (2nd ed.). Sweet & Maxwell. google scholar
• Lakop, E. F., & Sida, H. (2022). Factors Contributing to Dispensing Errors among Dispensers in Gulu Regional Referral Hospital, Gulu District. A Cross-sectional Study. Student’s Journal of Health Research Africa, 3(6), 16. https://doi.org/ google scholar
• Momo, K., Yasu, T., Kuroda, S., Higashino, S., Mitsugi, E., Ishimaru, H., Goto, K., Eguchi, A., Sato, K., & Matsumoto, M. (2022). A survey of near-miss dispensing errors in hospital pharmacies in Japan: DEPP-J study—multi-center prospective observational study. Biological and Pharmaceutical Bulletin, 45(10), 1489–1494. https://doi.org/10.1248/bpb.b22-00355 google scholar
• Mullan, K. (2002). Pharmacy law and practice. Blackstone Press. google scholar
• Pharmaceutical Services Division, Ministry of Health Malaysia. (2016). Guide To Good Dispensing. https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/gdsp-2016-final.pdf google scholar
• Pharmaceutical Services Programme, Ministry of Health Malaysia. (2009). Guide^ line on Medication Error Reporting, (1st ed.). https://www.moh.gov.my/moh/ attachments/4437.pdf google scholar
• Pharmaceutical Services Programme, Ministry of Health Malaysia. (2011). Pharmacy Practice and Development QAP Indicators 2010 Man^ ual. https://pharmacy.moh.gov.my/sites/default/files/document-upload/ pharmacy-practice-development-qap-indicators-2010-manual.pdf google scholar
• Pharmaceutical Services Programme, Ministry of Health Malaysia. (2019). Guideline on Medication Error Reporting System (MERS), (2nd ed.). google scholar
• Rajah, R., Hanif, A. A., Tan, S. S. A., Lim, P. P., Karim, S. A., Othman, E., & Teoh, T. F. (2019). Contributing factors to outpatient pharmacy near miss errors: a Malaysian prospective multi-center study. International Journal of Clinical Pharmacy, 41, 237–243. https://doi.org/10.1007/s11096-018-0762-1 google scholar
• Sadeghi, N. S., Maleki, M., Gorji, H. A., Vatankhah, S., Mohaghegh, B., Raouf, M., Abdollahi, L., Samie, F., & Askari, H. (2022). Comparison of non-teaching and teaching hospitals in Iran as an integrated medical education system and health services. Iranian Red Crescent Medical Journal, 24(7), e1707. https://doi. org/10.32592/ircmj.2022.24.7.1707 google scholar
• Samsiah, A., Othman, N., Jamshed, S., Hassali, M. A., & Wan-Mohaina, W. M. (2016). Medication errors reported to the National Medication Error Reporting System in Malaysia: a 4-year retrospective review (2009 to 2012). European Journal of Clinical Pharmacology, 72(12), 1515–1524. https://doi.org/10.1007/s00228-016-2126-x google scholar
• Tharini, R., & Low, J. (2021). Medical law and ethics in Malaysia. LexisNexis. google scholar
• Tu, H.-N., Shan, T.-H., Wu, Y.-C., Shen, P.-H., Wu, T.-Y., Lin, W.-L., Yang-Kao, Y.-H., & Cheng, C.-L. (2023). Reducing medication errors by adopting automatic dispensing cabinets in critical care units. Journal of Medical Systems, 47(1), 52. https:// doi.org/ google scholar
• Vandenbroucke, J. P., Von Elm, E., Altman, D. G., Gøtzsche, P. C., Mulrow, C. D., Pocock, S. J., Poole, C., Schlesselman, J. J., Egger, M., & Initiative, S. (2007). Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Medicine, 4(10), e297. https://doi.org/ google scholar
• Yatim, M. F. M., & Othman, N. H. (2022). A retrospective analysis of medication errors at a tertiary hospital in a northern state of Malaysia. Malaysian Journal of Pharmaceutical Sciences, 20(2), 79–92. https://doi.org/ google scholar