Evaluating Risk Factors to Commit Medication Errors in Hospital Pharmacy Operations



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Purpose: Financial constraints and increased awareness of medication errors are two prevailing factors that influence hospital pharmacy operations. Hospital pharmacy increasingly has to do more with less, potentially increasing the pharmacist’s risk of committing medication errors. Evaluating and minimizing these risk factors can lead to a safer, more efficient work environment. The purpose of this study is to identify modifiable and non-modifiable risk factors that increase a pharmacists risk to commit errors during the medication order verification process.

Methods: A retrospective, observational study of pharmacist-related medication errors was conducted from July 2011 to June 2012. Medication error data was obtained from the institution’s voluntary reporting system. Risk factors that were assessed were workload (average number of orders verified per pharmacist per shift), work environment (type of day, type of shift, and average number of pharmacists per shift), and non-modifiable pharmacist characteristics (type of pharmacy degree obtained, age, number of years practicing, and number of years at the institution). Statistical analysis was conducted using univariate analysis and multivariate logistic regression.

Results: A total of 1,887,751 medication orders, 92 PSN error events and 50 pharmacists were included in the study. The overall error rate identified per 100,000 orders verified was 4.87. The workload stratified analysis demonstrated an increasing rate of error associated with an increasing number of orders verified per pharmacist (p = 0.007). The work environment analysis had significant error rate differences for type of shift, type of day, and average number of pharmacists per shift categories (p = 0.021, 0.002, 0.001, respectively). The pharmacist demographic variables (degree, number of years practicing, number of years at site, age) did not have statistically significant outcomes.

Conclusions: Type of shift, type of day, average number of pharmacists per shift, and average number of orders verified per pharmacist can be utilized as medication safety benchmarks in hospital pharmacy.



Pharmacy, Hospitals, Order verification