Direct Observation Approach for Medication Errors Detection in an Educational Hospital

Armin Pourhosseiny; Mohammad Hossein Dehqani; Adeleh Sahebnasagh; Farnoosh Mirjalili; Fatemeh Saghafi

doi:10.18502/jpc.v10i1.9124

Armin Pourhosseiny Student Research Committee, School of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
Mohammad Hossein Dehqani Department of Anesthesia and Critical Care, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
Adeleh Sahebnasagh Clinical Research Center, Department of Internal Medicine, Faculty of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran.
Farnoosh Mirjalili Student Research Committee, School of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
Fatemeh Saghafi Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

DOI: https://doi.org/10.18502/jpc.v10i1.9124

Keywords: Medication Error; Observation; Patient Safety

Abstract

Background: Mistakes occur inevitably, but medication errors can cause catastrophic consequences such as death, which accentuates investigation through presumptive sources and possible solutions for the prevention of errors that took place before.

Methods: Twelve different medical wards of an educational hospital were analyzed using the direct disguised observation (DDO) method for administration step and chart review for prescription step. Each ward was randomly chosen, and the time at which the researcher presented oneself to each ward was contingent. The researcher observed the medicine continuously from the time prescribed by the physician until the drug finally entered the patient's body.

Results: Of 1350 dose of drugs, which were evaluated; 65% of data was collected in the morning shift (n=867), 28.6% in the afternoon shift, 6.4% of the night shift. About one-third of the physician orders were defective and did not contain all six parameters (drug name, dosage form, dose, measuring unit, administration route, and intervals of administration). Interpretation of the administration phase revealed 69% of drugs were erroneously administered due to errors detected as wrong route, omission, wrong dose, wrong time, and unauthorized dose.

Conclusion: Our findings exhibit errors in the pivotal stages of the therapy process. Clear instructions and protocols should be implemented for hospital technicians, nurses, and physicians to avoid irreparable detriments caused by medication errors.