Amal Al-Sibai Saudi Gazette JEDDAH — News of medication errors that severely affected patients' health has buffeted the healthcare system in the Kingdom several times this year, and in some of these cases have even led to the death of the patient. Headlines were made in March of this year when a female university student went into coma at a hospital in Jazan as a result of wrong medication. That was the third reported life-threatening medical error in Jazan within a month. Last month, at a hospital in Hafr Al-Batin, a male patient after successful surgery was transferred to his room which he shared with another patient. The nursing team accidentally switched medication between the two patients, and administered an injection to the patient which was supposed to be given to his roommate. The patient immediately slipped into coma and was rushed to the ICU, as previously reported. We heard similar stories in Jeddah and other cities as well. Those are incidences of medication errors that were actually brought to public attention. Medication errors in Saudi Arabia are, to a large extent, under reported. One effective method to prevent such errors in the first place is to explore, study, and identify the factors associated with the root causes of these errors and to educate hospital staff across the country on the findings. One study conducted at King Khalid University Hospital in Riyadh over a one-year-period from 2009 to 2010 revealed that 949 medication errors had occurred from among 240,000 prescriptions. During this period, 14 errors were categorized as resulting in harm to the patient. The most common types of errors were due to mistakes in prescribing (44 percent) and improper dose/quantity (31 percent). The types of medications that were most commonly involved in the errors were antibiotics, anti-hypertensive agents (medicines used to lower high blood pressure), and medicines that lower blood glucose levels. Surprisingly, illegible or unclear handwriting was reported as the cause of 17 percent of medication errors. A more recent study published in the International Journal of Clinical Pharmacology was conducted by Dr. Mansour Tobaiqy and Dr. Derek Stewart to explore the experiences of healthcare professionals around medication errors and medication error reporting in Saudi Arabia. The study aimed to determine the number, type, and severity of medication errors in the last 12 months, to address the barriers to reporting errors to health authorities, and to recommend strategies to improve error reporting. “Medication errors are failures in the treatment process that lead to, or have the potential to lead to, harm to the patient. “Error can occur at any stage of the patient medication journey; during prescribing, administration, and dispensing. “To promote patient safety, systematic processes must be in place for the identification, reporting, and implementation of change that will minimize medication errors,” said Tobaiqy, leader of the study and consultant pharmacologist and public safety proponent in the Ministry of Health, Jeddah. “Compromising patient safety due to medication error is a key global concern. There is a clear need for review of education and training of all healthcare professionals in the Kingdom and the development of fully transparent reporting mechanisms which are efficient and provide usable and informative data. Qualitative work focusing on better understanding of the complex human behavior around medication errors is also urgently required,” added Tobaiqy. The study was conducted at the Maternity and Children's Hospital in Jeddah and was approved by the ethical committee of the Ministry of Health Research Centre in Jeddah. The participants in the study reported observing 51 errors in the last 12 months. Out of the errors, the largest percentage was attributed to wrong medication prescribed and other reasons were the wrong dose prescribed, insufficient drug monitoring of patient, inappropriate route of administration of the drug, prescription duplication, and equipment failure. How the errors impacted the patients in this study varied. Five resulted in hospitalization of the patient, four led to prolongation of hospital stay, four were considered to have caused patient harm, but with no likely effect on duration of stay, and one patient was transferred to the intensive care unit. Advocates of patient safety have long been claiming that there is a scarcity of medical error reporting in the Kingdom. The hospital staff questioned in this particular study admitted that just over half of these errors had been reported to the Total Quality and Management Department using the standardized reporting form, as per the local policy and about 46 percent of errors were never even reported. Barriers to medical error reporting include lack of awareness of the reporting policy; workload and time constraints associated with reporting; and unavailability of the reporting form, lack of anonymity, and fear of blame. Suggested strategies to improve detecting, reporting, and reducing medication errors are continuing education events and seminars, an internet/web based reporting facility, training focused on error prevention, anonymity of reporting, and a non-punitive reporting culture. Hopes are that the more accurate the reporting is, the more cautious hospital staff will become, and in turn, the number of medication errors will decrease.
