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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 10-21

Interventions aimed at reducing medication errors in Saudi hospitals: A systematic review


Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Submission27-Sep-2021
Date of Acceptance29-Dec-2021
Date of Web Publication30-Mar-2022

Correspondence Address:
Douha F Bannan
Department of Pharmacy Practice, King Abdulaziz University, P.O. Box 80260, Jeddah 21589
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjcp.SJCP_3_21

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  Abstract 

Medication error is a preventable problem and different interventions can be used to prevent the occurrence of errors. The aims of this study were to describe interventions used to reduce prescribing, dispensing, and administration errors in hospitalized patients in Saudi Arabia, and to describe the impact of interventions used. Six databases were searched for articles published between 1985 and June 2021. Studies reporting impact of interventions on prescribing, dispensing, or administration errors were included. Interventions were summarized using the Template for Intervention Description and Replication (TIDieR) Checklist and Guide. Five studies met the inclusion criteria, all of them were before/after studies. Three studies used bundle interventions and two studies used a stand-alone intervention, which were education, training, standardized table, drug information service, counselling, unifying reorder days, and double-checking. One study described the intervention fairly well, the other four studies were of low quality. There is a limited number of studies that investigated interventions used to reduce errors in Saudi hospitals, the majority of which were with low quality. There is a need for higher-quality studies that explicitly state details such as how the intervention was chosen, how it was implemented, and the impact of the intervention on reducing errors.

Keywords: Hospitals, medication errors, patient safety, prevention and control, Saudi Arabia


How to cite this article:
Bannan DF. Interventions aimed at reducing medication errors in Saudi hospitals: A systematic review. Saudi J Clin Pharm 2022;1:10-21

How to cite this URL:
Bannan DF. Interventions aimed at reducing medication errors in Saudi hospitals: A systematic review. Saudi J Clin Pharm [serial online] 2022 [cited 2022 Jul 6];1:10-21. Available from: http://www.sjcp.org/text.asp?2022/1/1/10/341440


  Introduction Top


Medication error is a known inherent risk with the use of medications.[1] It can be defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.”[2] Medication errors may have no consequences, minimal, few, or serious consequences on patients. Yet, medication errors could threaten the safety of patients.[1] Evidence has shown that medication errors could contribute negatively to patient safety in terms of prolonged hospitalization, increase in direct and indirect cost, and overall health of patients. In the United States (US) and the United Kingdom (UK), medication errors impacted more than 7 million patients and accounted for billions of dollars every year.[3],[4],[5]

More emphasis has been made on patient and medication safety following the publication of the landmark report “To Err is Human”[6] in 1999. Medication error was considered as an inevitable, yet preventable, by-product of medication use.[6],[7] Thus, many studies about incidence, prevalence, causes, and interventions to reduce the occurrence of errors have been conducted in countries such as the US, the UK, and Australia. In addition, numerous interventions have been investigated such as education, training, dosing aids, and written materials.[8]

In Saudi Arabia, the emphasis on patient and medication safety is relatively new. Many studies have been published in the last few years; most of them were on incidence or prevalence of errors. Evidence showed that medication errors are common in Saudi hospitals; incidence rate of 44% according to a recent systematic review.[9] In addition, a retrospective observational study of more than 250 hospitals in Saudi Arabia reported 71,332 errors between 2018 and June 2019. The classes most frequently associated with errors were antimicrobial, analgesic, and hematinic (14%, 9.4%, and 8.4%, respectively). Most errors (66.3%) were class B; errors that occurred but did not reach the patients. However, there were several errors that required intervention.[10]

Interventions are needed to reduce errors and their impacts on patients and healthcare systems. Although many interventions have been used in other countries,[11],[12],[13] relying on these interventions could have its drawbacks. Most of the published studies may not be generalizable to Saudi hospitals for many reasons such as being conducted in individual healthcare settings, which might have different health care structure. In addition, underlying causes of errors can vary from a country to another which is an important factor when designing effective interventions. The aims of this review were (1) to describe interventions used to reduce prescribing, dispensing, and administration errors in hospitalized patients in Saudi Arabia and (2) to assess the impact of these interventions.


  Materials and Methods Top


Source

The following databases were searched to find studies published from 1985 to 2021: Cochrane Central Register of Controlled Trials (CENTRAL), Excerpta Medica Database (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE-PubMed), Cumulative Index to Nursing and Allied Health Literature (CINHAL EBSCO), Saudi Digital Library (SDL), and Google Scholar. Based on the research question, search was divided into five concepts: medication errors, interventions, settings, participants, and location. All possible search terms related to each concept were identified. Search terms used are available in Appendix A [Additional file 1]. Finally, references of included studies were checked for potentially eligible studies.

Inclusion and exclusion criteria

Study designs

Any study with comparison groups was included in the search. These types of studies (such as controlled before and after studies) were included because they would have measured the impact of interventions (our outcome) rather than just reporting the rate of errors. Studies without a comparison group (e.g., review studies), and studies without enough information to assess for inclusion or quality (e.g., conference abstracts) were excluded. Because English and Arabic were the two languages that the author could speak and critically understand, studies published in other languages were excluded.

Participants

Studies that focused on children and adults of any age that were carried out in Saudi hospitals were included. Studies carried out in the hospital but not in in-patient areas (e.g., outpatient clinics) were excluded. This is because other settings might have different prescribing, dispensing, or administration processes than those in hospitals.

Medication errors

The focus was on studies that investigated prescribing, dispending, and administration errors in hospitalized children and adults (definitions we used when searching the literature[14],[15],[16] are available in Appendix B) [Additional file 2]. Only prescribing, dispending, and administration errors were included, as these were the common types of errors found on Saudi hospitals.[9]

Intervention

Studies that investigated single or bundle (more than one intervention used at the same time) interventions were included. The comparison for this review was the rate of error before the implementation of the intervention(s) compared with the rate of the error after the implementation of the intervention(s).

Search strategy

The author evaluated the articles for eligibility, downloaded potential studies, and screened them for inclusion. Then, the full-text studies were retrieved and screened for inclusion. Ineligible studies (e.g., not related to the topic, no comparison group, no full-text available, or was not conducted in Saudi Arabia) were excluded. When needed, the author consulted an expert in the field to assist during the screening phase. In addition, the author contacted the authors of included studies when further information was needed to clarify reported information to either include or exclude the study.

Data extraction

Data were extracted using a standardized extraction form that was piloted on two studies. The finalized extraction form included the following information: publication year, location, study design, period, setting (wards included), number of participants and their age (e.g., children, adults, or elderly), definition(s) and type of error(s), definition(s), number(s), and type(s) of interventions used, intervention components, data collection methods, results (including main outcomes), limitations of the study, and other relevant information.

Assessment of risk of bias

The author assessed the risk of bias using prespecified criteria.[17],[18] The author consulted experts in the field during the assessment of risk of bias and the authors of included studies were contacted when further information was needed to clarify reported information (e.g., missing outcome data that might have introduced bias). The following sources of bias were assessed: selection bias (i.e., assessment of confounding), performance bias (i.e., blinding of personnel or assessment of fidelity of interventions), attrition bias (assessment of withdrawals from the study), and detection bias (assessment of blinding of outcome assessors). Studies were rated as low, moderate, high, or unclear. In addition, interventions used were assessed based on the level of detail provided such as why, what, and how interventions were delivered. Interventions were summarized in a separate form using the Template for Intervention Description and Replication (TIDieR) Checklist and Guide.[19]


  Results Top


Search process

After the initial search of the database, 1,569 citations were identified. Duplications were removed, and the remaining 1,537 studies were screened based on the title and abstract. After the exclusion of 1,288 studies, 249 studies were retrieved. Of those, 244 studies were excluded (e.g., irrelevant, no comparison group, in another country). Finally, five studies[20],[21],[22],[23],[24] were included in this review. The study attrition diagram is available in [Figure 1].
Figure 1: Study attrition diagram

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Quality of evidence

The risk of bias of the included studies is available in Appendix C [Additional file 3]. All the included studies were of low quality because all of them were simple before/after studies. When Selection bias was assessed, one study[21] was of low risk because the same databases and drug information resources were available in all desktops in the hospital. Another study[23] was of high risk because it was not known whether the same person delivered the interventions and whether it was standardized or not. Performance bias or measurement of exposure was unclear in most of the studies. It was low in one study[23] where participants had to take an exam after the educational sessions. In another study[20] performance bias was rated as low risk as counseling was given to patients and documented. Detection bias was not feasible to assess in most of the studies because of the design of the studies and interventions. One study[20] explicitly stated that it was non-randomized, others did not mention randomization or blinding of assessors. Finally, attrition bias was unclear for most of the study as most of them did not assess withdrawals from the studies. One study[20] followed up with participants and therefore rated as low risk. All five studies obtained ethical approval from their institutions.

The level of detail for interventions used was either unclear or low. Three studies provided justification for the selection of the intervention(s) and why they believed it might work. Two studies provided details of interventions used. For example, one study[23] explicitly stated for how long the intervention was used and not just stating the pre- and post-intervention phases. Another study[24] explicitly stated who delivered the intervention, how it was delivered, and where. The remainder three studies[20],[21],[22] did not adequately describe the interventions used. Intervention adherence/fidelity was not assessed in most of the studies.

Study characteristics

The characteristics of the included studies are available in [Table 1]. Three studies addressed two types of prescribing errors; dosing errors and omission, one study addressed adverse drug events, and one study addressed medication errors in general. Studies were conducted in the two biggest cities in Saudi Arabia: the majority were in Jeddah (3/5, 60%), and the remainder were in Riyadh (2/5, 40%). Duration of studies ranged from 3 to 6 months, 3 months (3/5, 60%), 5 months (1/5, 20%), and 6 months (1/5, 20%).
Table 1: Characteristics of included studies

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Settings

Most studies (4/5, 80%) were carried out in different wards in tertiary hospitals; one study was conducted in an internal medicine ward, one study in an intensive care unit, one in a surgical ward, and one study in a pediatric inpatient ward. The remainder (1/5, 20%) were carried out in a secondary care hospital without specifying the wards involved.

Definitions

There was nonuniformity in definitions provided by studies. Definitions of errors addressed in the studies are available in Appendix D[Additional file 4]. Two studies used definitions adapted from other studies,[25],[26] two studies used their own definition, and one study did not provide a definition. Al Subhi et al.[23] listed the various types of prescribing errors and defined some of them. Aseeri[24] focused on one type of prescribing errors (dosing error) and used a definition that was adapted and modified from published research.[25] Alomar et al.[22] also focused on one type of prescribing errors (missing dose or omission). However, the authors did not mention a definition of missing dose. Alkatheeri et al.[21] investigated medication errors in general. However, the definition they used focused on administration errors.

Methods of error detection

Several methods were used in data collection: The information system of the hospital,[23] observation then questionnaire through telephone calls,[20] the electronic reporting of the hospital and a questionnaire,[21] pharmacist/nurse communication slip record,[22] and antibiotic order sheets.[24]

Denominator

The denominators used to calculate the rate of errors in the five studies are available in [Table 2]. Two studies used number of orders, one study used number of patients, and two studies did not report the denominator used.
Table 2: Impact of interventions

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Interventions

The impact of the interventions on error reduction is available in [Table 2]. Three studies[20],[22],[24] showed an error reduction rate of approximately 90%, and two studies[21],[23] showed a non-significant reduction of 22.6% and 17%, respectively.

Five interventions were used, some as a stand-alone intervention while others as bundle interventions. A description of the interventions, including information such as why the interventions were used, what was used, and who provided the interventions, is available in [Table 3].
Table 3: Summary of interventions

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  Discussion Top


The description of interventions used to reduce prescribing, dispensing, and administration errors in hospitalized patients in Saudi Arabia and the impact of the used interventions were reported.

Different interventions of different impacts were reported in this review. These interventions were education, training, standardized table, drug information service, counseling, unifying reorder days, and double-checking. According to the hierarchy of intervention effectiveness,[27] interventions can be arranged from less effective/human-oriented interventions at the bottom of the effectiveness pyramid to more effective/system-oriented interventions at the top of the pyramid. The first level is punishment, which has no value. The next level has education and training. Rules and policies are the next level after education and training followed by reminders, checklist, and double check. On the contrary, simplification and standardization are near the top of the pyramid.[27]

Education and training are commonly used together as a bundle intervention, but they target different things. Education addresses the knowledge deficits, whereas training addresses skills needed when applying knowledge. Al Subhi et al.[23] used education as part of a bundle intervention; lectures (i.e., education) and hand-on experience of ordering medications using the electronic system (i.e., training) and reported a 17% reduction in errors rate, which was not statistically significant. Education and training are only one level above punishment, which has no value and is at the base of the hierarchy of intervention effectiveness pyramid.[27] Education and training are human-oriented interventions (knowledge and skills deficits). With some evidence suggesting that (most of the times) medication errors are due to system failure rather than due to individual’s competence or knowledge,[28],[29] education and training may not be effective in reducing errors.

Evidence from the literature about the impact of education was inconclusive, especially when used alone. For example, a study by Kozar et al.[30] assessed the impact of 30-min tutorials on prescribing errors made by physicians in emergency department found that errors were reduced from 46 errors per 363 orders to 66 errors per 533 orders (not statistically significant). Another study by Campino et al.[31] investigated the impact of 15 informative sessions found that prescribing errors reduced from 868 errors in 4182 orders to 47 errors in 1512 orders (P < 0.001).

When education was used with other interventions that have another function, for example, education and training with interventions such as pre-printed order sheet, written materials, or feedback, errors were reduced. A study by Bertsche et al.[32] found that administration errors were reduced from 40.4% to 7.9% after giving lectures, training sessions, and the distribution of written materials in a pediatric neurological ward. Al-Subhi et al.[23] used education with training, which target different functions. However, little detail was given as to how the lectures or training was given (for example, face-to-face or virtual) and whether they were given as intended or not. In addition, it was known whether the problem of prescribing errors was due to lack of knowledge and deficiency of skills needed to apply knowledge or due to other causes. Education and training could be added to a bundle of interventions to make sure the target population has the knowledge and skills required to prescribe, dispense, or administer before implementing other interventions.

Written materials are a good strategy to improve access to information. When used, it is important to make sure and assess whether participants were able to and had in fact accessed this information. In Alkatheeri et al.,[21] the aim was to improve access to up-to-date information such as databases. When the intervention was implemented, medication errors were reduced from 93 errors to 72 errors, but that reduction was not statistically significant. The assessment of participants’ experience was based on 86 questionnaires. However, it was not known how many questionnaires were distributed at the beginning, the response rate, and whether this number was representative of all healthcare providers in the hospital. Another point worth mentioning is the data collection methods. Alkatheeri et al.[21] used the electronic reporting system. Under-reporting is a well-known problem with self-reporting. A study found that 44.8% of healthcare providers never report errors.[33] There might be more errors and the intervention might have reduced errors even more, but errors where not reported prior to the implementation of the intervention.

According to the hierarchy of intervention effectiveness,[27] rules and policies are more effective in reducing errors than education/training. When Alomar et al.[22] used policies, such as unifying the re-order day and double-checking of medications at the time of receiving, missing doses reduced from 735 incidents to 71 incidents. The two interventions were used at the same time, and it was not known which one of the interventions was more effective. Evidence on the impact of double-checking when used alone was not conclusive. It might be possible that the new policy had a superior effect or that the two interventions had a synergetic effect when used together.

The other intervention used was standardization in the form of a standardized table for antibiotics used as a dosing aid to reduce dosing errors.[24] This intervention reduced errors by approximately 90%. The level of detail of how well the study was conducted was sufficient and a team with multidisciplinary members taught participants how to appropriately use the table. However, it was not known whether, in fact, participants used the table when prescribing or rely on their previous knowledge or other sources they usually use. According to the hierarchy of interventions effectiveness, standardization is a more effective intervention compared to education, training, or policies as it is system oriented. Evidence on its effectiveness showed that standardization reduced errors rates. A study by Wong et al. found nurses had no administration errors when used a dosing chart compared to 80% nurses who had no errors when using traditional source or information.

Medication counseling was used in one study.[20] Medication counseling was an activity by the pharmacist aimed at improving the use of medications and reduce adverse drug events.[20] The intervention reduced errors by 90.5%. However, intervention adherence or fidelity was not assessed. It is not known whether counseling was given as intended or the quality of counseling. In Alghamdi et al.,[20] counseling was accompanied by written materials handed to patients. Therefore, it is not known whether the reduction in adverse drug events were due to counseling or written materials, or the bundle of interventions. In addition, adverse drug events data was collected from patients using a telephone call. Participants were asked questions such as whether they had experienced adverse drug events and medications caused them. However, having a clear definition and understanding of what adverse events mean is important. Adverse drug events might be mistaken by adverse drug reactions, or side effects. The distinction between these terms is not straightforward for healthcare providers nether the less patients. It was not mentioned in the study whether it was clear for patients or not.

Medication errors and their subtypes have different definitions. Different terms might mean different things. In the included studies, authors either did not define errors, created their own definitions, or referred to definitions used by other authors. This would add to the numerous definitions already reported in the literature. A systematic review[34] that looked at various definitions used by organizations for medication safety terms such as errors, medication errors, and preventable adverse drug events showed that more than 100 definitions were reported in the literature for medication safety-related terms. Using a standardized definition of a local, national, or international organizations might be helpful and more reliable when measuring errors. In addition, having a standardized definition of different types of errors would be useful when collecting errors, comparing number of errors, or reporting results.

Interventions might work better if targeting the causes of errors. In the included studies,[20],[21],[22],[23],[24] some designed the interventions based on the causes of errors in the setting, others did not mention the rationale behind selecting the interventions [Table 3]. Many healthcare institutions might be asked to rationale their use of resources. Future studies might focus on identifying causes of errors before designing interventions to maximize the impact of interventions.

Medication safety is not a new topic in Saudi Arabia, and it was a topic of interest to many organizations such as the Saudi Food and Drug Authority (SFDA). However, in the past few years, more emphasis was made on patient and medication errors. The Saudi Patient Safety Center (SPSC) was established in 2017 that focuses on patient safety.[35] Since then, the literature on incidence, prevalence, or causes of errors has increased tremendously. However, a recent review[36] about contributory factors to positive safety culture in Saudi Arabia found that factors such as poor communication and blame culture among the factors hindering positive culture. More emphasis is needed to activate the role of medication safety officer in hospitals and overcome the negative view of medication errors reporting to improve the literature on interventions to overcome the problem of medication errors.

The quality of included studies varied as well as the level of detail of reported information. Aseeri[24] explicitly described the interventions (where, when, and who delivered it) and the rate of prescribing errors (who collected the data, where, and denominator used) and showed that the intervention used was effective. Other studies have not reported the denominator used. In Alkatheeri et al.[21] and Alomar et al.,[22] the number of errors was reduced from 93 errors to 72 errors and from 735 errors to 71 errors, respectively. It is not known for example whether the 93 and 72 errors were found in an equal number of orders or not. Without a complete description of error detection methods (e.g., who collected the data, how errors rates were calculated, denominator used) how errors’ rates were calculated, and how interventions impacts were measured it would be hard for researchers or other healthcare providers to replicate the interventions or build on the findings. Studies with a higher quality are needed to assess the real impact of interventions used in the included studies.

The review has a few advantages and some limitations. To the best of our knowledge, this is the first systematic review that summarized and systematically appraised evidence about interventions used in Saudi hospitals aimed at reducing prescribing, dispensing, or administration errors. We used six databases when searching for evidence to include all potential studies. We intended to conduct a meta-analysis, but because of insufficient number of studies with similar interventions was found, a meta-analysis was not feasible. Lastly, only one author conducted the systematic review. To overcome this issue, the author consulted expert in the field of medication safety and study designs when assessing the quality of included studies.


  Conclusion Top


Medication error is a threat to hospitalized patients everywhere. Only a few studies have investigated the impact of interventions on reducing medication errors in hospitalized patients in Saudi Arabia. Although some studies used a single stand-alone intervention, others used bundle interventions. However, most of the studies were of low quality. There is a need for higher-quality studies that explicitly state details such as how the intervention was chosen, how it was implemented, and the impact of the intervention on reducing errors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

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    Tables

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  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
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