Assessment of the medication safety practice package developed and implemented among pharmacists in a tertiary care hospital

Abstract

Medication errors pose significant risks in healthcare. This study piloted the implementation of a medication safety practice package (MSPP) for pharmacists, addressing key factors responsible for errors. An eight component MSPP was developed through studies conducted among pharmacists and patients, considering key medication safety aspects and was finalized during consultative meetings. The package comprised: a High-Alert Medicine (HAM) list with Error Prevention Strategies (EPS), Look-Alike-Sound-Alike (LASA) medicine list with EPS, Error-Prone Abbreviation (EPA) list with EPS, templates for dispensing labels for all pre-packed medicines in local languages, guidelines for patient education and counselling including patient information leaflets (PILs) for 10 HAMs, guidelines for safety in polypharmacy, medication reconciliation and reporting of medication incidents. The MSPP was distributed among all pharmacists (N=45) in a tertiary care hospital and implementation was evaluated using a structured, interviewer-administered questionnaire assessing awareness, acceptability, and adherence to the recommendations after one year. Awareness about the components of the MSPP were; HAM (95.6%), LASA medicines (84.4%), EPA (84.4%), patient education and counselling (64.4%), polypharmacy (70.5%), medication reconciliation (68.9%), and incident reporting (93.3%). Self-reported adherence to recommendations was 100% for HAM, LASA and medicines labelling. Counselling for first visit patients was done by 95.6%. Being cautious on polypharmacy was reported by 60% and medication reconciliation by 91.1%. Although 77.7% knew the procedure of reporting, none had reported incidents. The main barriers to implementing the MSPP were a heavy workload (86.7%), high patient volumes (77.8%), inadequate staffing (91.1%), poor patient health literacy (95.6%), and the absence of a separate patient counseling area (97.8%). This pilot study showed the feasibility of implementing eight components of the MSPP despite these barriers. Reducing workload and increasing the number of staff would support implementation. Incident reporting culture needs improving to learn and prevent errors. The MSPP can be extended to other hospitals.