title: A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan.
abstract: BACKGROUND
  Administering medication is one of the high risk areas for any health professional. It is a multidisciplinary process, which begins with the doctor's prescription, followed by review and provision by a pharmacist, and ends with preparation and administration by a nurse. Several studies have highlighted a high medication incident rate at several healthcare institutions.
  
  
  METHODS
  Our study design was exploratory and evaluative and used methodological triangulation. Sample size was of two types. First, a convenient sample of 1000 medication dosages to estimate the medication error (95% CI). We took another sample from subjects involved in medication usage processes such as physicians, nurses, pharmacists, and patients. Two sets of instruments were designed via extensive literature review: a medication tracking error form and a focus group interview questionnaire.
  
  
  RESULTS
  Our study findings revealed 100% compliance with a computerized physician order entry (CPOE) system by physicians, nurses, and pharmacists. The main error rate was 5.5% and pharmacists contributed an higher error rate of 2.6% followed by nurses (1.1%) and physicians (1%). Major areas for improvement in error rates were identified: delay in medication delivery, lab results reviewed electronically before prescription, dispension, and administration.
authors.affiliation: Division of Nursing Services. khurshid.khowaja@aku.edu
authors.forename: Khurshid
authors.initials: K
authors.lastname: Khowaja
authors.forename: Rozmin
authors.initials: R
authors.lastname: Nizar
authors.forename: Rashida J
authors.initials: RJ
authors.lastname: Merchant
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Dias
authors.forename: Irma
authors.initials: I
authors.lastname: Bustamante-Gavino
authors.forename: Amina
authors.initials: A
authors.lastname: Malik