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Table of Contents
REVIEW ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 106-114

Medication errors in Jordan: A systematic review


1 Department of Clinical Pharmacy, College of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
2 Department of Adult Health Nursing, College of Nursing, Jordan University of Science and Technology, Irbid, Jordan
3 Department of Pharmacy, Royal Medical Services, Amman, Jordan

Date of Submission05-Aug-2021
Date of Acceptance23-Oct-2021
Date of Web Publication24-Jun-2022

Correspondence Address:
Dr. Abeer M Rababah
Department of Clinical Pharmacy, Jordan University of Science and Technology, PO Box 3030, Irbid 22110
Jordan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijciis.ijciis_72_21

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   Abstract 


Medication errors (MEs) present a significant issue in health care area, as they pose a threat to patient safety and could occur at any stage of the medication use process. The objective of this systematic review was to review studies reporting the rates, prevalence, and/or incidence of various MEs in different health care clinical settings in Jordan. We searched PubMed, HINARI, Google, and SCOPUS for relevant published studies. We included observational, cross-sectional or cohort studies on MEs targeting adults in different health-care settings in Jordan. A total of 411 records were identified through searching different databases. Following the removal of duplicates, screening of title, abstract and full-text screening, 24 papers were included for the final review step. Prescribing errors was the most common error reported in the included studies, where it was reported in 15 studies. The prevalence of prescribing errors ranged from 0.1% to 96%. Two studies reported unintentional discrepancies and documentation errors as other types of MEs, where the prevalence of unintentional discrepancies ranged from 47% to 67.9%, and the prevalence of documentation errors ranged from 33.7% to 65%. In conclusion, a wide variation was found between the reviewed studies in the error prevalence rates. This variation may be due to the variation in the clinical settings, targeted populations, methodologies employed. There is an imperative need for addressing the issue of MEs and improving drug therapy practice among health-care professionals by introducing education and training.

Keywords: Administration, dispensing, health services, Jordan, medication errors, prescribing


How to cite this article:
Rababah AM, Mardini AN, Ababneh MA, Rababa M, Hayajneh M. Medication errors in Jordan: A systematic review. Int J Crit Illn Inj Sci 2022;12:106-14

How to cite this URL:
Rababah AM, Mardini AN, Ababneh MA, Rababa M, Hayajneh M. Medication errors in Jordan: A systematic review. Int J Crit Illn Inj Sci [serial online] 2022 [cited 2022 Aug 19];12:106-14. Available from: https://www.ijciis.org/text.asp?2022/12/2/106/348009




   Introduction Top


Medication errors (MEs) have been defined by The National Coordinating Council for ME Reporting and Prevention as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health-care professional, patient, or consumer” (National Coordinating Council for ME Reporting and Prevention).[1] These errors pose a threat to patient safety, and may lead to many adverse consequences, such as patient harm (injury or disability), admission to hospital, increasing the duration of hospital stay, the cost of health care, and occasionally death.[2],[3]

MEs could occur at any stage of the medication use process, such as prescribing, transcribing, dispensing, and administration.[4] The stages that are associated with the most common errors are prescribing and drug administration.[5],[6] The worldwide incidence of MEs ranges from 2% to 14%.[3] The causes of MEs were identified and may include illegible handwriting, heavy workload, labeling errors,[7] interruptions, and distractions that health care professionals face during drug prescription and administration,[2],[3],[8] and wrong drug calculations.[4]

Organizational policies and procedures to prevent MEs should be established, and these procedures should be implemented in the every step of drug delivery.[9] Moreover, prompt reporting of any occurred MEs should be encouraged.[9] Furthermore, electronic prescribing as a tool helps against some errors that occur as a result of illegible handwriting and incompleteness of prescriptions, as using the mandatory fields in electronic prescribing ensures the completeness of the prescription.[5],[10] Another type of technology that could be used to prevent MEs is bar coding, in which using this technology in dispensing phase had led to a reduction in wrong MEs, a reduction in wrong dose errors, and a total elimination of incorrect dosage form errors.[11]

Recently, the research concerning MEs in Jordan is expanding. However, no previous comprehensive review of literature regarding MEs in Jordan has been undertaken. This review aimed to report the rates, prevalence, and/or incidence of various MEs in different health-care clinical settings in Jordan.


   Methods Top


Literature search and study design

A systematic review is the design of this study, and the protocol used was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.[12] The following databases were used as sources of data: PubMed, HINARI, Google, and SCOPUS. These databases were searched for relevant published studies from January 1, 2000, to November 17, 2020, and reviewed based on predefined inclusion and exclusion criteria. The current systematic review was designed to include articles written only in English. The complete search strategy was provided in Supplemental Appendix 1.

Study selection

Inclusion and exclusion criteria

The inclusion criteria of the current project focused on considering the studies dealing with MEs in adults (≥18 years) population, both inpatient or outpatient departments, and the studies that conducted in community or emergency departments. Furthermore, we included studies that described prescribed and/or over-the-counter medications, observational studies, cross-sectional or cohort analysis, which are suitable to estimate the incidence and prevalence of MEs or preventable adverse drug events. On the other hand, the following exclusion criteria have been applied in selection process of the current study. Review articles, conference papers, abstracts, unpublished theses, editorial reports, or letters to the editors with limited information have been excluded. Moreover, the exclusion criteria include studies focused on illegal substance abuse, herbal products, pediatric population (<18 years), MEs during pregnancy or published in other languages than English. The randomized controlled trials were excluded since these could not be used to reliably assess the incidence and/or prevalence of the outcomes of interest. Finally, we excluded studies describing and predicting the types and causes of adverse drug reactions.

Data extraction

Once we finished the searching for studies in the databases, the process of study selection was started. At first, duplicates were removed manually by AM. Second, the title and abstracts of the remaining studies were screened following the above eligibility criteria. This initial screening was performed by three researchers (AR, AM, and MA), and resulted in excluding many studies that fit with a certain exclusion criterion. RAYYAN software (http://rayyan.qcri.org/; Qatar Foundation Headquarter, Qatar) was used to filter the search and to facilitate the automated initial screening of the suggested abstracts and titles. Third, the remaining studies were assessed based on a full text screening to ensure eligibility following the above inclusion and exclusion criteria. In both screening stages, the reason of exclusion for the excluded studies was explained. In the current study, we used specific preidentified mesh terms, keywords, and Boolean operators to keep the search reproducible. Some Boolean operators (“AND” and “OR”) were used to combine between the search terms. All search results were downloaded as full text, and then after screening, the included studies were exported into the Endnote referencing software. The flow diagram of the whole process of study selection is shown in [Figure 1].
Figure 1: PRISMA flow diagram illustrating articles selection method. RCT: Randomized controlled trial

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Certain key information was extracted from the included studies and was recorded on separate sheets for organization. These are the general characteristics of the included studies (author, study setting, study design, study population, sample size, number of study settings), the rates, prevalence and/or incidence of certain types of MEs, and the prevalence of selected types of prescription errors.

Risk of bias assessment

For this study, we assessed the risk of bias using National Heart, Lung, and Blood Institute quality assessment tools (NHLBI) (https://www. nhlbi.nih.gov/health-topics/study-quality-assessment-tools). The quality for all included studies was evaluated using one checklist, which is Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. That is because the design of these studies was cross-sectional. The grey literature was excluded from the current study such as conference proceedings, unpublished theses, information that is not published in clearly comprehensible databases or journals, and studies that include the abstracts of research presented at conferences. To minimize publication bias, the present study was depending on high-quality search thorough literature reviews; hence, included all studies (that met the inclusion criteria) regardless their results, included articles that required a peer reviewer to acknowledge conflicts of interest, and excluded information that is not published in clearly comprehensible databases or journals. The studies were meticulously assessed based on a full text screening to ensure eligibility following the above inclusion and exclusion criteria. In both screening stages, the reason of exclusion for the excluded studies was explained. In the process of identifying the inclusion/exclusion criteria, we mainly utilized the Topic Refinement (Key Questions) process to minimize ambiguity. The criteria were set based on the analytic framework using NHLBI quality assessment tools.

Because all the studies were cross-sectional in their nature, measuring the exposures of interest prior to the outcomes and loss of follow-up were not applicable. Four papers[13],[14],[15],[16] out of 24 did not study the causes or risk factors (exposures) of MEs (outcomes), therefore evaluating the relationship between exposures and outcomes was not applicable as well as the exposures themselves. Only two studies[17],[18] measured the confounding variables, and five studies[17],[19],[20],[21],[22] blinded the outcome assessors. Salameh et al. 2018[23] clearly stated that the researcher (the person measuring the exposure) is one of the authors and therefore could also be an outcome assessor. In this case, it is most likely that the outcome assessor is not blinded. [Supplementary Table S1[Additional file 1]] contains further details.


   Results Top


The flow chart in [Figure 1] illustrates an outline of the study selection process. A total of 411 records were identified through searching different databases. Following the removal of duplicates, 317 candidate articles continued for title and abstract screening. According to the initial screening, 32 studies were subsequently selected for full-text assessment, and 24 papers met the inclusion criteria were included for the final review step. The remaining articles were excluded for different reasons [Figure 1].

Comprehensive review of the selected studies

A summary table for the general characteristics of the included studies is presented in [Table 1]. Overall, the included studies encountered 21,100 participants from different clinical settings. The clinical settings represented by the included studies were unicenter,[14],[16],[20],[23],[24],[25],[26],[27],[28] two centers[29],[30] and multicenter[17],[18],[19],[21],[22],[31],[32],[33],[34],[35],[36],[37] settings covering most parts of Jordan. Most of the included studies applied cross-sectional design, four studies used retrospective,[14],[25],[30],[37] and one represented their outcomes via applying descriptive correlational study design.[17] Moreover, Sulaiman et al.[26] and Ababneh et al.[29] employed prospective observational study design with direct observation and chart review methods. On the other hand, Abdel-Qader et al.[27],[37] used mixed design approach to study the incidence and causes of medication dispensing errors; combining prospective veiled observation and direct health-care providers interviewing. On the other hand, Walid Al-Qerem et al. utilized prescriptions review and direct interview methods to study the prevalence of potential drug-drug interaction in geriatric patients.[38] Most of the papers evaluated were conducted for hospitalized patients (n = 8), patients attending outpatient settings (n = 10) and emergency department (n = 1). Moreover, seven of the included papers either described Jordanian nurses' perceptions[17],[19],[32],[35] about different aspects of medications errors, or recorded observation incorporated the nurses who formulated and administered the medications.[20],[26]
Table 1: Summary table for the general characteristics of the included studies

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The rate, prevalence, or incidence of medication errors

[Table 2] shows the rates, prevalence, or incidence of MEs reported in the included papers classified according to the type of MEs. In this review, most of the included papers assessed prescribing, administration, and dispensing errors. For example, Al-Taani et al.[33] reported that 81.2% of total recruited patients within the outpatient settings have at least one medication related errors (represented as untreated indication, unnecessary drug, and efficacy issues). Moreover, Aburuz et al.[28] in their prospective study showed that almost all participated patients (98.3%) experienced at least one treatment related problems [Table 2]. The prevalence of prescribing errors presented by Ababneh et al.,[29] Abdel-Qader et al.,[37] Abu Hammour et al.,[25] Al-azayzih et al.,[24] Alqudah et al.,[14] Arabyat et al.,[34] Zalloum et al.,[30] and Sulaiman et al.[26] are 36.6%, 11.5%, 10.5%, 62.5%, 86%, 27.6%, 72.5% and 0.1% respectively [Table 2].
Table 2: The rate, prevalence or incidence of medication errors sorted according to the type of medication errors

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Another example for MEs, the cross-sectional study conducted by Haddadin et al.[21] indicated that almost one third (30.2%) of the dispensed antibiotics in Jordanian community pharmacies were without prescriptions [Table 2]. Alrabadi et al.[35] described that ~83.4% of the nurses conveyed <1 error/year. Moreover, Alkhawaldeh et al.[20] indicated that 27.3% administration errors appeared among registered nurses working at the hematology and oncology departments at King Hussein Cancer Center and Jordanian Royal Medical Services. Alshara et al.[19] declared via their questionnaire-based study that the nurses administration errors represented the highest level of MEs, reported as giving the drug in a wrong time (8.7%), inappropriate dose (22.2%), to the wrong patient (26.2%) or by giving the incorrect medications (9.5%) [Table 2]. Additionally, two studies in this systematic review reported the presence of potential drug-drug interaction, which is considered a type of MEs (91%[38] and 96%[18]).

Abu Moghli et al.[16] anticipated other types of MEs reported as unintentional discrepancies (drug omissions, additions, wrong drug, or dose) and intentional undocumented discrepancies (documentation errors). They reported that 67.9% of participants experienced at least one unintentional discrepancy with 65.1% of them being omissions.[16] Moreover, 33.7% documentation errors were also recognized [Table 2]. On the other hand, Salameh et al.[23] identified 65% of the study participants having documentation errors, and 47% were retrieved to have at least one unintentional discrepancy[23] [Table 2].

In this systematic review, the prevalence of prescription errors ranged from 0.3%[36] to 89.8%[28] [Table 3]. Frequently identified prescription errors types were efficacy and indication related errors (89.8% and 74.63%, respectively),[28] inappropriate dosage regimen (68.5%[21] and 50.3%[32]), untreated conditions (68.3%),[32] ineffective or incomplete drug therapy (74.9%[32]) and a need for additional or more frequent monitoring (41.73%)[36] [Table 3]. Most of the included studies reported at least one drug without an indication or unnecessary drug therapy (34.7%,[32] 27.6%,[34] 26.1%[33] and 2.47%[36]). Further, two studies[29],[32] reported the presence of actual or potential drug interaction [17.7% and 10.2% respectively; [Table 3]].
Table 3: The rate or prevalence of medication errors in selected articles classified according to the type of prescription errors

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   Discussion Top


This systematic review aimed at reporting the rates, prevalence, and/or incidence of various MEs in different health care clinical settings in Jordan. Reporting MEs is crucial for patient safety and optimal health outcomes. This review found a relatively few numbers of MEs studies conducted in Jordan compared to the number from other Middle Eastern countries.[39] To best of our knowledge, this is the first systematic review appraising MEs in Jordan. This systematic review has demonstrated limited evidence regarding MEs in Jordan. For example, no information was reported on the sample size of one of the selected national studies that targeted 350 community pharmacies across the country.[37] In addition, many studies focused on outpatients[18],[20],[24],[29],[32],[33],[34],[36],[38] with only one study reported the incidence rates of MEs.[27]

The present study highlighted several types of MEs such as prescribing, administration transcribing, dispensing errors, documentation and treatment-related errors. “Pharmacist counselling” and “nurse-related” were other examples of MEs reported in this review. In addition, the review findings reported high prevalence of prescription errors with more frequent errors being related to drug efficacy and indication. Prescribing errors is a prevalent issue, worldwide.[40],[41] The high prevalence rates of prescribing errors reported in this review comes consistent with the ones reported in two previous systematic reviews conducted in the Middle East[39] and the West[42] to explore the prevalence of prescribing errors in inpatients and outpatients. The finding of the current review that prescribing errors are among the most commonly reported types of MEs and correlated with efficacy related errors and inappropriate dosage regimen comes in consistent with previous studies[43],[44] and recent systematic review.[39]

Consistent with previous studies,[45],[46] transcribing errors were the least frequently reported MEs since the transcribing stage was not as important as prescribing and dispensing stages in medication treatment process. However, Lisby et al.[47] considered the medication transcription as the stage where most MEs could occur. In the present systematic review, only two studies evaluated transcribing errors with no further information mentioned about what types of those transcribing errors were. The limited evidence in the literature about transcribing stage may mislead the real statistics about the prevalence and incidence rates of transcribing errors.

This systematic review had several limitations. First, both prospective and retrospective studies are combined in this review although there would be differences in the prevalence of MEs identified using different methods of chart review; either retrospective or prospective. Second, not all reviewed studies reported the rates of MEs as percentages. Basheti et al.,2019 reported MEs rates as a mean and standard deviation. The representativeness of the reviewed studies is limited, and the generalizability of the present review findings should be discussed with caution since approximately one-half of the studies were conducted in single hospitals. This review was designed to include articles written only in English, which may introduce a selection bias. Some articles written in Arabic, which is the original language in Jordan, might be missed.

Future research is recommended to increase healthcare professionals' and students' awareness of MEs. Hence, we encourage the development of educational and training programs discussing pharmacotherapy and examine their effectiveness in promoting the knowledge, attitude, and practice of medication prescribing, administration, and dispensing. Further exploring of barriers and facilitators to MEs reporting among health care professionals is warranted.


   Conclusion Top


This is the first systematic review to report on MEs in Jordan. Despite the relatively small number of reviewed studies related to MEs in Jordan, a wide variation was found between those studies in the error prevalence rates. This variation may be due to the variation in the clinical settings, targeted populations, methodologies employed. Most of the studies targeted inpatients and outpatients, while very few studies were conducted on healthcare professionals. Most studies reported on prescribing errors. There is an imperative need for addressing the issue of MEs and improving drug therapy practice among health-care professionals by introducing education and training.

Research quality and ethics statement

This study did not require approval by the local Institutional Review Board/Ethics Committee, as it relied on previously published and publicly available data. The project was not registered prospectively with PROSPERO. The authors followed the applicable EQUATOR Network (http://www.equator-network.org/) guidelines, specifically the PRISMA Guidelines, during the conduct of this research project.

Acknowledgment

The librarian work was supported by the library at Jordan University of Science and Technology.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.


   Supplemental Appendix Top


Appendix 1: Literature Search Strategy

PubMed

(“Treatment-related problem*” [Mesh] OR “Medication-related problem*” [Mesh] OR “Drug-related problem*”[Mesh] OR “Medication error*”[Mesh] OR “Adverse drug reaction*”[tiab] OR “Drug-drug interaction*”[tiab] OR “Adverse drug event*” [tiab] OR “Drug-related side effect*”, “Drug-Related Side Effects*” [Mesh] OR “Adverse Reaction*” [Mesh] OR “Drug therapy problem*”[Mesh] OR “Indication-related problem*”[Mesh] OR “Effectiveness-related problem*”[Mesh] OR “Drug compliance*” [Mesh] OR “Adherence*” [Mesh] OR “Adverse drug event*” [Mesh] OR “Safety related problem*”[Mesh] OR “Self-medication*” [Mesh] OR “Polypharmacy*” [Mesh] OR “Multiple drug*” [Mesh] OR “Drug-food interaction*”[Mesh] OR “Overdose error*” [tiab] OR” Drug toxicity*”.

AND

“Dosing error” [Mesh] OR “Wrong dose” [Mesh] OR “Non-optimal dosing” [tiab] OR “Sub-optimal dosing” [tiab] OR “Dosing schedule error” [Mesh] OR “Dispensing error” [Mesh] OR “Unnecessary drug” [tiab] OR “Additional drug” [Mesh] OR “Allergy-related error” [Mesh] OR “Pharmaceutical drug form” [Mesh] OR “ Laboratory test” [Mesh] OR “Drug monitoring” [Mesh] OR “Wrong time of administration” [Mesh] OR “delayed Administration” [Mesh] OR “Medical chart error” [Mesh] OR “Wrong dose administered” [Mesh] OR “Error”, “Jordan”.

Scopus

“Treatment-related problem” OR “Drug-related problem” OR “Medication error” OR “Drug-drug interaction” OR “Adverse drug event” OR “Drug-related side effect” OR “Drug therapy problem” OR “Effectiveness-related problem” OR “Adverse drug event” OR “Self-medication” OR “Multiple drug” OR “Drug-food interaction” OR “Overdose error” OR “Drug toxicity” OR “Dosing error” OR “Dosing schedule error” OR “Dispensing error” OR “Unnecessary drug” “Wrong time of administration” OR “delayed administration” OR “Medical chart error”.

HINARI

“Medication-related problem” OR “Drug-related problem” OR “Medication error” OR “Adverse drug reaction” OR “Drug-drug interaction” OR “Adverse drug event” OR “Drug therapy problem” OR “Effectiveness-related problem” OR “Adverse drug event” OR “Safety related problem” OR “Self-medication” OR “Overdose error” OR” Dispensing error” OR “Unnecessary drug” OR “Additional drug” OR “Allergy-related error” OR “Pharmaceutical drug form” OR “Wrong time of administration” OR “Delayed administration” OR “Medical chart error”.

Google

“Treatment-related problem*”, “Medication-related problem*”,“Drug-related problem*”,“Medication error*”,“Adverse drug reaction*”,“Drug-drug interaction*”,“Adverse drug event”, “Drug-related side effect”, “Drug-Related Side Effects and Adverse Reaction”,“Drug therapy problem*”,“Indication-related problem*”, “Effectiveness-related problem*”,“Drug compliance”,“Adherence”,“Adverse drug event”, “Safety related problem*”,“Self-medication”,“Polypharmacy”, “Multiple drug”, “Drug-food interaction*”, “Overdose error”,“Drug toxicity”, “Dosing error”, “Wrong dose”, “Non-optimal dosing”, “Sub-optimal dosing”, “Dosing schedule error”, “Dispensing error”, “Unnecessary drug”, “Additional drug”, “Allergy-related error”, “Pharmaceutical drug form”,” Laboratory test*”,“Drug monitoring”, “Wrong time of administration”, “Delayed administration”, “Medical chart error”, “Wrong dose administered”, “Error”, “Jordan”. Some Boolean operators (”AND” and “OR”) were used to combine between the search terms.



 
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