Detection and Prevention of Medication Errors in Operating Rooms of Pediatric Surgery Department

Abstract

Medication errors are widespread in the health care system and stated to be the seventh most common cause of death overall. The role of clinical pharmacist in controlling medication use in the operating rooms in Egypt is not clearly defined. The objective of thisstudy was to investigate the role of clinical pharmacist in the detection, reporting and prevention of medication errors in a pediatric surgery department in Cairo, Egypt. In this pre-post study, medication errors were detected in two groups of patients. Direct observation and chart review methods were used for detection of the errors. The type, category, stage of medication errors, in addition to who committed and who detected the error were determined for each error detected in both pre- and post-intervention groups. Five drug classes were studied that included: anti-microbials, anesthetics, analgesics, gastrointestinal agents and miscellaneous drugs. The intervention included educating physicians and anesthesiologists about detection, reporting and prevention of medication errors, and involvement of a clinical pharmacist in the surgery department. A total of 312 medicationerrors were detected in the pre-intervention group out of 936 medication orders for 110 patients, and 224 medication errors were detected in the post-intervention group out of 693 medication orders for 112 patients (P= 0.67). The intervention resulted in a significant reduction in low-dose errors (P=0.005) and high-dose errors (P=0.001). Other types of medication errors were reduced at different rates. Additionally, there was a significant reduction in number of prescribing errors post-intervention (P<0.05). Category C medication errors were significantly reduced post-intervention (P<0.05). Clinical pharmacist has an essential role in reducing medication errors in the preoperative setting.