Ainul Mawaddah Suhaime AFFINDI, Mohamad Azizul Mohd LATIP, Norkasihan IBRAHIM, Shamala BALAN, Yogini JANI, Muhammad Asyraf HARUN, Noraiza Abdul RAHMAN
İstanbul Journal of Pharmacy - 2025;55(3):470-479
Background and Aims: The progression of near-miss medication errors may lead to patient harm and legal implications. The magnitude and characteristics of near-miss medication errors in teaching hospitals are poorly understood. This study aimed to analyse near-miss medication errors at two teaching hospitals. Methods: Medication errors reported in year 2022 were retrieved from the hospital database and screened to collect data on the types of error, medications involved, and contributing factors for near-miss prescribing error (NMPE) and near-miss dispensing error (NMDE) from the outpatient (OPD) and inpatient (IPD) pharmacy departments. Descriptive and chi-square (chi2) analyses were conducted to evaluate NMPE and NMDE by settings. Results: Of the 4657 reports, 3148 (67.6%) and 1509 (32.4%) were NMPE and NMDE, respectively. OPD had a higher rate of NMPE (1.76%, 95% CI 1.69-1.83%) than IPD (1.0%, 95% CI 0.78-1.16%). The rate of NMDE in the IPD was threefold as compared to that in the OPD [1.28% (1.21-1.35%) vs. 0.38% (0.28-0.32%)]. The medications from the alimentary tract and metabolism group (n = 936/4644, 20.16%) were commonly involved in near-miss medication errors. The primary contributing factor was confusion with the electronic prescribing system (511/2022, 25.27%). Near misses of inappropriate regimens were more likely in OPD (chi2(2) = 14.7, p<0.001). Near misses of labelling were more likely in the IPD (chi2(1) = 7.5, p<0.001). Conclusion: Near-miss medication errors were prevalent, with distinct patterns observed in outpatient and inpatient settings. Strengthening electronic prescribing processes and reducing system-related confusion may enhance medication safety in teaching hospitals.
