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Effective methods to detect medication administration and its related errors in surgical wards by clinical pharmacist at a tertiary care hospital - a single blinded study

Badr Ali Gassar, Balakeshwa Ramaiah, Mustafa Ali, Raju koneri



The goal of this study was to investigate the feasibility method between “direct observation” and “medication chart review” in detection of medication errors. 


This single-blind observational study was focused to explore the suitable method to capture the error that occurs during drug administration. Direct observation was used to detect medication errors on each day upon directly observing the nurses while administering the medications. In the medication chart review process, all available case information sheets were thoroughly investigated to identify any associated errors in the case. Then, the observer analyzed the collected data and finally reported the errors for the concerned clinicians.

Key Findings:

Total doses of 12572 in 558 patients were observed over a period of six months. The rate of errors detected by direct observation was 22.5% while medication chart review was 20 %.  Bedside storage without prescription were the most common frequent error (n=526, 50.9%). Unauthorized drug use errors were frequent administration errors (n=61, 21%), followed by the wrong time (n=56, 19.3%). Documentation error were the most frequent error (n=406, 29.6 %) and followed by inappropriate abbreviations (n=350, 25.52%) used.


Both of the methods were proved to be efficient and reliable. The direct observation method was able to capture a higher number of medication errors primarily related to administration errors compared to the medication chart review. The medication chart review method was able to capture the superficial information related to a medication error. Finally, the direct observation method was more effective to detect medication errors.


Medication Errors, Direct Observation, Medication Chart Review, Administration Errors, Clinical Pharmacist, Transcribing errors, prescribing errors


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