In this study, medication transcription errors where common among hospitalized patients, occurring in 1 out of every 4 patients. In a two-step transcription process, almost half of all errors occurred on both the medication administration sheet and the medication card. With regards to the type of errors, most were omissions of a stop or a new medication order. Antibacterial for systemic use were involved in more than half of all MTEs that occurred. The nurses in the wards identified illegible prescriptions, distractions, higher work load and negligence as the most likely causes of transcription errors.
The rate of MTEs observed in our study was higher than observed in an earlier report of hospitalized patients, where 5 MTEs were observed for every 100 admission (9). However, in another study conducted within an intensive care unit in Morocco, more than 400 MTEs occurred per 100 admissions (10). The observed differences might be accounted for by differences in the medication use process, targeted population, severity of illness, lack of uniformity in definitions for MTEs, and method of reporting of errors. From the literature, studies which focused on the reporting of prescription and administration errors showed low MTE rates (5, 11). The transcription step of the medication use process in our setting is two stage process and majority of the MTEs occurred in both stages. There is evidence that multiple steps in the medicine use process increase the likelihood of an error occurring and approaches that standardize and simplify the medication use process improve medication safety (12, 13).
The frequency of different error types reported depends on factors such as the study methodology, the medication use process within a particular setting, and the classification used for different error types. In this study, omission of start and stop orders were the most frequent MTEs observed which is in coherence with a previous report in an oncology unit that used a similar two step transcription process (14). Our findings, however, are not in agreement with other studies that reported incorrect patient, route of administration, frequency, and incorrect medication added (3, 10, 15). According to data from some studies wrong dose errors were consistently high in different settings and corroborate with findings from our setting were over 18% of MTEs were wrong doses (5). Most of the studies that categorized errors by type focused on prescription and administration errors and the differences in approach and methodology might have accounted for the discrepancies observed.
Findings from our study indicated that antibiotics for systemic use were the medicine class most frequently involved in MTEs which is in agreement with findings from several studies in other resource limited settings (5, 7, 9, 10, 15). In a prospective observational study within an intensive care unit in Morocco by Naoual and colleagues, anti-infective medications were involved in the highest proportion of errors (33%) which was lower than what was observed in our study (10). Another study among hospitalized children reported a higher rate (71%) of antimicrobials implicated in medication errors compared to our findings (9). Despite the differences in rates across studies, anti-infective medications were consistently involved in the highest number of medication errors across most studies in resource limited settings (5, 7, 9, 10, 15). This might be partially explained by the high prevalence of communicable diseases in these settings and increased consumption of antimicrobials among hospitalized patients leading to a higher chance of being involved in errors.
In a recent systematic review of medication errors and adverse events in hospitals across nine African countries, lack of knowledge, training, distractions, and high workload were frequently cited as factors which contribute to medication errors which is parallel with our findings (5). Nurse’s opinions of the likely causes of errors in our study are comparable to evidence from the literature, with the highest cause of MTEs attributed to illegible prescriptions as observed in earlier reports (15–17). Several strategies could be implemented to reduce the incidence of errors including; clear writing of orders that are non-confusing by prescribers, direct communication between all healthcare professionals involved in the medication use process, clarifications with prescribers for illegible prescriptions, adoption of computerized provider order entry systems, eliminating extended physician and nurses work schedule, and implementing medication reconciliation tools (10, 12, 13, 16, 18–20).
This study had some strengths in that it was a prospective observational study and the ward staff were blinded to avoid the Hawthorne effect. Also it was comprehensive as medication orders transcribed for all patients were analyzed from admission to discharge during the study period.
Despite the strengths of this study, there are a number of limitations. It was a single site study carried out within a small sample in two wards over a short period of time, hence the findings cannot be generalized to other hospitals in Cameroon. Also, examined a single step in the medication use process (transcription) and therefore does not present a comprehensive picture of medication safety practices in our setting. The incidence of MTEs could have reduced as the study progressed because the clinical pharmacist intervened where transcription errors were identified and nurses within the wards might have become more cautious. Also we did not assess the potential severity of MTEs identified and this could give a better picture of the scale of the problem in future studies.