CP-085 Role of the hospital pharmacist in preventing near miss transcription errors

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Transcription is considered a critical step in the medication use process, particularly in hospitals that do not utilise any computerised physician order entry systems. Sequentially, pharmacists are responsible for order verification, a step that follows transcription. Accordingly, they are the last safety net to intercept and correct near miss transcription errors before reaching the patient


The objective of this study was to assess the role of hospital pharmacist in preventing and reporting transcription errors

Material and methods

This was a retrospective observational study. All hospitalised patients in a tertiary care hospital admitted from January 2009 to December 2015 were included. Patients’ charts were screened for errors by clinical pharmacists. Medication related physician orders and home medication discharge orders were reviewed. All detected errors in the medication use process were recorded using a validated medication error reporting form.


734 transcription errors were identified in the charts of 30440 patients. Most reported transcription errors occurred in the department of internal medicine (72.3%) followed by surgery (9.9%). Approximately 52.9% of reported medication errors occurred with prescribed parenteral medications and 35% with orally administered drugs. Antimicrobials and cardiovascular medications were the main drug classes affected (24.5% and 14.8%, respectively). Results showed that the reasons behind errors were wrong doses (21.8%), drug omissions (20.6%), wrong medications (17.3%) and wrong drug frequencies (15.7%). Errors were classified as near miss in 91.3% of cases, while only 8.7% were considered errors that reached the patient with no harm done. It was noted that wrong dose and wrong bar code increased significantly the severity of errors, compared with drug omission (p=0.026 and p=0.001, respectively). With regard to drug classes, the results showed that analgesics, and respiratory and antidiabetic medications increased significantly the risk of errors compared with antibiotics (p=0.011; p=0.029; p=0.002, respectively). Finally, reporting errors from the medicine or surgery ward increased significantly the risk of error, compared with reporting from the pharmacy department (p=0.049).


In the absence of health information systems, pharmacists play a major role in preventing near miss transcription errors and securing patient safety. This is a continuous process through vigilant surveillance, proactive audits and effective reporting.


No conflict of interest

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