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. 2023 Jun;89(6):1724-1735.
doi: 10.1111/bcp.15694. Epub 2023 Mar 17.

Factors influencing in-hospital prescribing errors: A systematic review

Rashudy F Mahomedradja  1   2   3 , Michiel Schinkel  4   5 , Kim C E Sigaloff  1   2   3 , Michael O Reumerman  1   2   3 , René H J Otten  6 , Jelle Tichelaar  1   2   3 , Michiel A van Agtmael  1   2   3
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Free article

Factors influencing in-hospital prescribing errors: A systematic review

Rashudy F Mahomedradja et al. Br J Clin Pharmacol. 2023 Jun.
Free article

Abstract

Aim: In-hospital prescribing errors (PEs) may result in patient harm, prolonged hospitalization and hospital (re)admission. These events are associated with pressure on healthcare services and significant healthcare costs. To develop targeted interventions to prevent or reduce in-hospital PEs, identification and understanding of facilitating and protective factors influencing in-hospital PEs in current daily practice is necessary, adopting a Safety-II perspective. The aim of this systematic review was to create an overview of all factors reported in the literature, both protective and facilitating, as influencing in-hospital PEs.

Methods: PubMed, EMBASE.com and the Cochrane Library (via Wiley) were searched, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, for studies that identified factors influencing in-hospital PEs. Both qualitative and quantitative study designs were included.

Results: Overall, 19 articles (6 qualitative and 13 quantitative studies) were included and 40 unique factors influencing in-hospital PEs were identified. These factors were categorized into five domains according to the Eindhoven classification ('organization-related', 'prescriber-related', 'prescription-related', 'technology-related' and 'unclassified') and visualized in an Ishikawa (Fishbone) diagram. Most of the identified factors (87.5%; n = 40) facilitated in-hospital PEs. The most frequently identified facilitating factor (39.6%; n = 19) was 'insufficient (drug) knowledge, prescribing skills and/or experience of prescribers'.

Conclusion: The findings of this review could be used to identify points of engagement for future intervention studies and help hospitals determine how to optimize prescribing. A multifaceted intervention, targeting multiple factors might help to circumvent the complex challenge of in-hospital PEs.

Keywords: education; medication safety; prescribing errors; risk factors.

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References

REFERENCES

    1. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274(1):29-34. doi:10.1001/jama.1995.03530010043033
    1. Assiri GA, Shebl NA, Mahmoud MA, et al. What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ Open. 2018;8(5):e019101. doi:10.1136/bmjopen-2017-019101
    1. De Vries T, Henning RH, Hogerzeil HV, Fresle D, Policy M, World Health Organization. Guide to Good Prescribing: A Practical Manual. Geneva: World Health Organization; 1994.
    1. Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients. Drug Saf. 2009;32(5):379-389. doi:10.2165/00002018-200932050-00002
    1. World Health Organization. Medication Errors. Geneva: World Health Organization; 2016.

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