Medications errors (MEs) have been a major concern of healthcare systems\nworldwide. Voluntary-based incident reporting is the mainstay system to detect such events in many\ninstitutions. However, the number of reports can be highly variable across institutions depending\non their adoption of the safety culture. This study aimed to evaluate and analyze medication error\nincidents that were submitted through the hospital safety reporting system in 2015 at a tertiary care\ncenter in the western region of Saudi Arabia, and to explore the most common types of harmful MEs\nin addition to the risk factors that led to such harmful incidents. Methods: This is a descriptive study\nthat was conducted utilizing 624 medication error reports extracted from the hospital safety reporting\nsystem. Reports were analyzed based on the medication name, event type, event description, nodes\nof the medication use process, harm score (adapted from the National Coordinating Council for\nMedication Error Reporting and Prevention harm index), patientsâ?? age/gender, incident setting, and\ntime of occurrence as documented in the Safety Reporting System (SRS). Furthermore, all errors\nthat resulted in injury or harm to patients had a deeper review by two senior pharmacists to find\ncontributing factors that led to these harmful incidents and recommend system-based preventive\nstrategies. Results: This study showed that most reported incidents were near misses (69.3%).\nThe pediatric population was involved in 28.4% of the incident reports. Most of the reported incidents\nwere categorized as occurring in the inpatient setting (57.4%). Medication error incidents were\nmore likely to be reported in the morning shift versus evening and night shift (77.4% vs. 22.6%).\nMost reported incidents involved the dispensing stage (36.7%). High-alert medications were reported\nin 281 out of 624 events (45%). Conclusions: The hospital medication safety reporting program is a\ngreat tool to identify system-based issues in the medication management system. This study identified\nmany opportunities for improvement in the medication use system, especially in management of\nchemotherapy and anticoagulant agents.
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