Perception of reporting medication errors including near-misses among Korean hospital pharmacists

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Medication errors threaten patient safety by requiring admission, readmission, and/or a longer hospital stay, and can even be fatal. Near-misses indicate the potential for medication errors to have occurred. Therefore, reporting near-misses is a first step in preventing medication errors. The aim of this study was to estimate the reporting rate of near-misses among pharmacists in Korean hospitals, and to identify the factors that contributed to reporting medication errors.

We surveyed 245 pharmacists from 32 hospital pharmacies for medication errors, including near-misses. We asked them to describe their experiences of near-misses in dispensing, administration, and prescribing, and to indicate the percentage of near-misses that they reported. Additionally, we asked questions related to the perception of medication errors and barriers to reporting medication errors. These questions were grouped into 4 categories: protocol and methods of reporting, incentives and protections for reporters, attitude related to reporting, and fear. Descriptive statistics and logistic regression were conducted to analyze the data.

Five or more near-misses per month were experienced by 14.8%, 4.3%, and 43.9% of respondents for dispensing, administration, and prescribing errors, respectively. The percentages of respondents who stated that they reported all near-misses involving dispensing errors, administration errors, and prescribing errors were 43.7%, 57.4%, and 37.1%, respectively. Unclear reporting protocols and the absence of harm done to patients were significant factors contributing to the failure to report medication errors (P < .05).

Advances can still be made in the frequency of reporting near-misses. Clear and standardized policies and procedures are likely to increase the reporting rates.

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