Stewardship of Medication Errors in a Developing Country’s Scenario: A Clinical Pharmacist’s Role

A three-year prospective cohort study in a South Indian hospital involving 20,256 hospitalized patients over 18 years old identified 13,310 medication errors, yielding an incidence rate of 6.4%. Administration errors were the most common at 38.2%, followed by prescribing and transcribing errors at 28%, and dispensing and medication procurement errors at 17% each. Clinical pharmacists were the primary reporters of these errors (51%), with nurses and doctors reporting 31% and 17%, respectively. Most errors were classified as Category A (no harm) or Category B (33% each), with root causes being distractions, workload, and communication issues. Analgesics and antibiotics were frequently involved, and risk factors included longer hospital stays, multiple medications, comorbidities, and work shifts. The study concluded that active involvement of all stakeholders in a non-punitive medication error reporting system, with clinical pharmacists playing a key role, significantly enhances patient safety.