title: The pattern of the discovery of medication errors in a tertiary hospital in Hong Kong.
abstract: BACKGROUND
  The primary goal of reducing medication errors is to eliminate those that reach the patient.
  
  
  OBJECTIVE
  We aimed to study the pattern of interceptions to tackle medication errors along the medication use processes.
  
  
  METHODS
  Tertiary care hospital in Hong Kong.
  
  
  METHODS
  The 'Swiss Cheese Model' was used to explain the interceptions targeting medication error reporting over 5 years (2006-2010).
  
  
  METHODS
  Proportions of prescribing, dispensing and drug administration errors intercepted by pharmacists and nurses; proportions of prescribing, dispensing and drug administration errors that reached the patient.
  
  
  RESULTS
  Our analysis included 1,268 in-patient medication errors, of which 53.4% were related to prescribing, 29.0% to administration and 17.6% to dispensing. 34.1% of all medication errors (4.9% prescribing, 26.8% drug administration and 2.4% dispensing) were not intercepted. Pharmacy staff intercepted 85.4% of the prescribing errors. Nurses detected 83.0% of dispensing and 5.0% of prescribing errors. However, 92.4% of all drug administration errors reached the patient.
  
  
  CONCLUSIONS
  Having a preventive measure at each stage of the medication use process helps to prevent most errors. Most drug administration errors reach the patient as there is no defense against these. Therefore, more interventions to prevent drug administration errors are warranted.
authors: Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong.
authors: N R
authors: NR
authors: Samaranayake
authors: S T D
authors: ST
authors: Cheung
authors: W C M
authors: WC
authors: Chui
authors: B M Y
authors: BM
authors: Cheung
mesh_terms: D064420:Drug-Related Side Effects and Adverse Reactions; D006723:Hong Kong; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008962:Models, Theoretical; D009726:Nurses / Q000458:organization & administration / Q000706:statistics & numerical data; D004364:Pharmaceutical Preparations / Q000008:administration & dosage; D010595:Pharmacists / Q000458:organization & administration / Q000706:statistics & numerical data; D010607:Pharmacy Service, Hospital / Q000458:organization & administration; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D062606:Tertiary Care Centers
chemical_list: D004364:Pharmaceutical Preparations