Medication errors and associated factors among pediatric inpatients in public hospitals of gamo zone, southern Ethiopia

Abstract

1. Introduction

Medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is under the healthcare professional, patient, or consumer's control. These occurrences could be related to professional practice, healthcare products, procedures, and systems, such as prescription, order, communication, labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use [[1], [2], [3]].

Medication errors (MEs) are the most common medical errors worldwide, especially in pediatrics [4]. In a review article involving 113 intensive care units (ICUs) from 27 countries, 74.5% of the participants experienced MEs [5]. A study in India found that 68.5% of the medication end up with errors [6]. Similar to many developing countries MEs are common in Ethiopia; a study conducted at Jimma University Specialized Hospital (JUSH) and Tigray found that 89.9% and 62.7% of pediatric inpatients encountered medication errors, respectively [7,8]. Furthermore, 75.5% of children in western Ethiopia experienced MEs [9].

Previous empirical studies reported that lack of adequate staffing, medical complications, lack of therapeutic training, inadequate drug knowledge, minimal experience, work overload and poor communication, distractions, interruptions, lack of standardized protocols and procedures, and insufficient resources are associated with MEs [[10], [11], [12], [13], [14]].

Pediatric inpatients require medication to be prescribed individually based on their age and body weight [15]. They are the most vulnerable group of clients, susceptible to a wide range of errors; particularly, low birth weight and preterm babies are more vulnerable to the adverse squeal of medication inaccuracies due to their limited ability to 'buffer' such errors [16,17]. Furthermore, the scarcity of pediatric formulations and a lack of manufacturer information on how to prepare these medications raises the risk of errors in children [[17], [18], [19], [20]].

Medication errors can result in either preventable or unpreventable adverse drug events [21,22]. A systematic review of 51 studies from nine African countries found that 8.4% of children experience adverse drug events [23]. According to a South African study 16% of children died as a result of adverse drug reactions [24]. Similarly, a study in Nigeria discovered 40 suspected adverse drug reactions out of 53 medications administered [25]. Although the majority of errors are minor, some fatal errors result in serious injury or death [26,27]. Evidence revealed that 1.5–71% of pediatric inpatients experience adverse drug events [9,[28], [29], [30], [31]] and 2.9% died [24] as a result of MEs. Furthermore, MEs increase the length of hospital stay, medical costs, parental distress, and erode public trust in healthcare services [32].

Safe medication administration is the foundation for proper patient care [33]. Understanding how and why MEs occur, as well as working as a team in a "culture of safety", and providing employees with a working environment that protects them from human fallibility, is critical to implementing a successful intervention to reduce MEs [34,35]. Medication review and reconciliation (MedRec) automated information systems, in-service training, and multicomponent interventions have a significant impact on ME reduction [14,34]. Furthermore, medication administration rights serve as a foundation for improving MEs. The Food, Medicine, and Health Care Administration and Control Authority (FMHACA) also emphasizes avoiding excessive drug use and assisting health institutions at various levels in the development and dissemination of standard treatment guidelines [36]. However, in low and middle-income countries these standards are not effectively implemented [14,33].

Despite studies focused on MEs have been conducted in developed countries, such evidences are insufficient in the context of Sub-Saharan Africa. As far as our knowledge concerned there is no concrete evidence regarding MEs and their associated factors among pediatric inpatients in Ethiopia. Thus, the purpose of this study was to determine the prevalence and associated factors of medication errors among pediatric inpatients in public hospitals of Gamo zone, southern Ethiopia.

2. Methods and materials

3. Results

3.1. Participant's characteristics

A total of 416 pediatric inpatients were involved in this study, with a response rate of 98.8% and a total hospital stay of 2601 patient days. Among the participants, 116 (27.88%) were within the age group of 29–365 days, 260 (62.5%) were male, 299 (71.88%) were rural dwellers, and 280 (67.31%) of the child's family were involved in the medication administration process. The patients' mean weight was 10.64 Kg (SD ± 8.64). Most, 385 (92.55%) of the participants were conscious, 102 (24.60%) appeared acutely ill, 103 (24.76%) had a history of medical illness, 62 (14.9%) received five and above medications, and 231 (55.53%) stayed in the hospital for more than 5 days (Table 2). Over 137 medical conditions were identified as reasons for admission; one-fifth (19.5%) were admitted due to pneumonia. Furthermore, 74 (17.8%), 69 (16.6%), and 54 (13.0%) were admitted due to meningitis, severe acute malnutrition, and sepsis, respectively (Fig. 1).

Table 2

Background characteristics of pediatric inpatients in Gamo zone public hospital, Southern Ethiopia, 2021 (n = 416).

Variables	Category	Frequency	Percentage
Age category	≤28 days	101	24.28
	29–365 days	116	27.88
	1–3 years	75	18.03
	4–6 years	43	10.34
	7–10 years	48	11.54
	≥10 years	33	7.93
Sex	Male	260	62.50
	Female	156	37.50
Residence	Urban	117	28.12
	Rural	299	71.88
Weight in Kg	<5	124	29.81
	5 to 10.99	154	37.02
	11 to 19.99	75	18.03
	≥20	63	15.14
Family involvement in childcare	Yes	280	67.31
	No	136	32.69
Level of consciousness	Conscious	385	92.55
	Unconscious	31	7.45
Severity of the disease	Healthy looking	94	22.65
	Acute sick looking	102	24.60
	Sub-critical	127	30.53
	Critical	79	19.00
	Severe	14	3.37
Previous history of medical illness	Yes	103	24.76
	No	313	75.24
Diagnosis criteria	Empirical	75	18.03
	Laboratory investigation	18	4.33
	Both empirical and laboratory investigation	323	77.64
Number of diseases per patient	1	192	46.15
	2	138	33.17
	≥3	86	20.67
Number medications per patient	≤2	189	45.43
	3–4	165	39.66
	≥5	62	14.90
Hospital stays in days	≤5	185	44.47
	>5	231	55.53

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Fig. 1

Top fifteen reasons for pediatric patient admission in Gamo Zone public hospitals, Southern Ethiopia, 2021 (n = 416).

3.2. Medication prescription-related characteristics

During the study period, 1253 medications were prescribed, with 1174 (93.69%) ordered by physicians and medical interns. The healthcare provider in charge of the medication prescription had an average experience of 14.43 (SD of ±27.56) months. Two-thirds of the medications, 790 (63.1%) were prescribed by male providers. None of the prescription papers contain all the standard prescription form components recommended by national guidelines; patients' weight (8.9%), address (8.7%), and gender (5.3%) were the most missed components to be written on the prescription papers (Fig. 2). Of the prescribed medications; 345 (27.53%), 324 (25.86%) and 178 (14.21%) were antibiotics, fluids, and analgesics/antipyretics, respectively. Moreover, 226 (32.47%) of the antibiotics, 148 (21.26%) of the fluids, and 98 (14.08%) of the analgesics/antipyretics ends up with errors (Table 3).

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Fig. 2

Information included in the prescription of pediatric inpatients in Gamo zone public hospitals, southern Ethiopia, 2020 (n = 416).

Table 3

Therapeutic categories of medications associated with medication errors in Gamo zone public hospitals, southern Ethiopia, 2020 (n = 1253).

Drug category	Medication errors		Total, N (%)
	Yes	No
Antibiotics	226 (32.47)	119 (21.36)	345 (27.53)
Fluids	148 (21.26)	176 (31.60)	324 (25.86)
Analgesia/antipyretics	98 (14.08)	80 (14.36)	178 (14.21)
Antimalarial	35 (5.03)	22 (3.95)	57 (4.55)
Cardiovascular drugs	26 (3.74)	25 (4.49)	51 (4.07)
Vitamins and minerals	31 (4.45)	22 (3.95)	50 (3.99)
Central nervous system drugs	23 (3.31)	46 (8.25)	69 (5.51)
Gastrointestinal drugs	14 (2.01)	29 (5.21)	43 (3.43)
Antifungal	20 (2.87)	8 (1.44)	28 (2.23)
Steroid	17 (2.44)	6 (1.08)	23 (1.84)
Bronchodilators	12 (1.72)	8 (1.44)	20 (1.60)
Metabolic drugs	2 (0.29)	4 (0.72)	6 (0.48)
Antivirus	4 (0.57)	2 (0.36)	6 (0.48)
Other	40 (5.75)	13 (2.33)	53 (4.23)
Total	696 (100)	557 (100)	1253 (100)

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3.4. Prevalence of medication errors

Medication errors occurred at a rate of 55.55, 167.31, and 26.76 per 100 orders, admissions, and patient days, respectively. Prescription and administration errors occurred in 247 (59.38%) and 175 (42.07%) of the participants, separately. Overall, 289 [69.5%, 95% CI: 64.80, 73.86] of pediatric inpatients experienced MEs. Among those who had MEs, 221 (53.13%), 61 (14.66%), and 48 (11.54%) encounter dosing, duration, and preparation errors, respectively (Fig. 3).

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Fig. 3

Types of medication errors among pediatric inpatients in Gamo zone public hospitals, Southern Ethiopia, 2021 (n = 416).

4. Discussion

Pediatric inpatients are more vulnerable to MEs due to inadequate buffering systems, resulting in severe disability and death [42]. In this study, 69.5% of the participants had at least one type of MEs. Unsuitable medication reconstitution environment, small weight, medication administered by diploma providers, non-involvement of parents in their child's medication administration process, non-adherence to medication administration rights, and prolonged length of hospital stay increase the likelihood of MEs.

In this study, 69.5% (95% CI: 64.80, 73.86) of pediatric inpatients experience MEs. The finding of the current study is higher than the studies conducted in Jimma University Medical Center, Ethiopia (41.8%) [43], JUSH (51.8%) [39], Tigray, Ethiopia (62.7%) [8] and tertiary hospitals in southwestern Nigeria (40.9%) [44]. However, this finding is lower than the studies conducted in JUSH (89.9%) [7], west Ethiopia (75.1%) [9], and South Africa (78%) [45]. This disparity could be attributed to work overload, healthcare providers’ experience and qualification, availability of medication safety-specific pieces of training, facilities infrastructure, medication administration guidelines, and computerized prescription and dose calculation machines.

According to our study, 59.4% of participants experienced prescription errors. This is higher than the results of studies conducted in Malaysia (7.3%) [46] and Brazil (43.5%) [47]. The possible justification is that the absence of electronic prescription, a large number of patients, absence of continuous training, and lack of a medical error-monitoring system could all be cited as contributing factors to this error. Evidence suggests that computerized provider order entry with electronic medication alert systems reduces prescription errors [48]. This study also found that 42.07% of participants encountered MAEs. This is higher than the study conducted at Addis Ababa, Black Lion Specialized Hospital, and Zewditu Memorial Hospital (35.5%) [49]. This variation may be due to the nature of the hospitals; specialized hospitals have senior professionals, relatively better infrastructure, training accessibility, and medication error reporting systems than general and primary hospitals. This finding, however, is lower than that of studies conducted in Tigray, Ethiopia (62.7%) [8] and JUSH (89.9%) [7]. This disparity may be due to a time difference; the JUSH study was conducted nearly ten years ago, and there have been significant improvements in healthcare provision over these years.

Participants treated by diploma professionals were 2.1 times higher risk to experience MEs compared to those treated by health professionals with at least a BSc level of education. This is in contrast to the study conducted in Tigray, Ethiopia, which found that medications administered by degree professionals had a 1.52 higher chance of error [8]. The possible justification is that knowledge or skill alone is insufficient to ensure medication administration safety; rather, the integration of these two domains is imperative. The study conducted at the University Hospitals of Cairo showed that 26.3% and 22.5% of MEs were committed by untrained and new staff respectively [50]. Furthermore, Wondmieneh et al., demonstrated that a lack of adequate training triples the likelihood of medication administration errors [51]. Evidence also suggests that inadequate knowledge and a lack of continuous training for healthcare providers are the main associated factors of various MEs [23].

The odds of MEs were 2.4 times higher among patients whose medications were reconstituted in an unsuitable working environment. Previous research has also shown that hospitals that adhere to the minimum standard of care reduce the occurrence of MEs [52,53]. A study in Tigray, Ethiopia, also found that MAEs were 13.5 and 4.1 times higher in facilities lacking a medication preparation room and medication administration guidelines, respectively [8]. This is because qualified healthcare providers alone cannot ensure medication safety without the availability of the bare minimum of hospital infrastructure.

Participants with a weight of less than 5 kg, 5–10.9 kg, and 11–19.9 kg have a 3.72, 2.78-, and 2.38 times higher risk of MEs than those with a weight of twenty and above. This is supported by the study in Tigray, which found that MAEs were inversely proportional to age [8]. This is most likely due to a lack of child doses; calculating a single dose for those with lower weight/age is difficult for healthcare providers, and they are more prone to errors.

Involvement of the child's parent in the medication administration process reduces the risk of MEs by 45%. This is consistent with a study that found involving family members in medical care reduced the occurrence of MEs and its associated harms by 30% [52]. This is because healthcare providers care for a large number of patients every day. Thus, involving parents in the child's medication administration process is critical to ensuring the care process and reminding the healthcare provider about the time of medication administration and any changes in the child's health condition.

Noncompliance with medication administration rights by healthcare providers increases the risk of MEs by 2.68-fold. Previous research backs this up: Tsegaye et al., discovered that failing to adhere to medication administration rights increases the likelihood of MAEs by 1.6 times [54]. Furthermore, a lack of knowledge about medication administration rights raises the risk of MEs [23]. The possible justification is that health professionals must have adequate knowledge, skills, and therapeutic communication; any break in the mediation process results in MEs. Poor nurse-physician communication, according to Aboshaiqah and colleagues, is also a major contributing factor to the high incidence of MEs [55].

Participants who stayed for more than five days had a 1.83 higher risk of MEs compared to those who stayed for less than or equal to five days. This is supported by a study conducted in western Ethiopia, which revealed that participants who stayed for five days or more had a 4.24 times higher risk of ME [9]. The possible justification is that the parent's ability to cover medical costs may decrease as the number of hospital stays increases, and the risk of omitting some prescribed drugs and leaving the hospital against medical advice is high.

In general, the incidence of MEs was high in the study hospitals; great emphasis should be given to improving medication safety. The findings of this study will assist clinicians to adhere to the national treatment guideline in prescription, medication selection, dose, frequency, and duration for a specific medical condition. The study also provides invaluable information to nurses to strictly adhere to medication administration rights. Furthermore, the study generates critical information for hospital administrators to meet the minimum requirements for medication administration, initiate mediation safety-specific training for healthcare providers, develop medication error reporting systems, and launch electronic charting systems that reduce MEs. Furthermore, the study generates critical information for interested scholars and stakeholders to use in designing appropriate interventions to reduce the occurrence of medical errors among pediatric inpatients.

The study has several strengths, which include: I) validated data collection tool with a repeated assessment for each prescribed medication; II) use of various data collection techniques such as interviewer-administered questioners, facility supervision, medical recorded review, and direct observation; and III) use of ODK tools for the data collection. Despite its strength, this study encountered limitations in observing medication administration during the night shift and in intensive care units. In those cases, we relied solely on recorded data, which may underestimate the occurrence of MEs. Moreover, the study only included general hospitals with high patient flow and the results do not represent other health facilities. Furthermore, observer bias and documentation errors may under or overestimate MEs.

5. Conclusions

Medication errors among pediatric inpatients were found to be high in the study hospitals as compared to similar studies in the country; dosing, duration, and preparation errors were common. Unsuitable working environment, low child weight, medication administered by diploma providers, involving the parent in the medication administration process, nonadherence with medication administration rights, and a prolonged length of hospital stay were significantly associated with MEs. Creating suitable working environment for medication reconstitution and administration, facilitate education and training for providers, involving families in the medication administration process, and strict adherence with medication administration rights are imperative to minimize medication inaccuracies.

Nationally harmonized treatment guidelines, electronic prescription/charting and dose calculation using machines, extensive medication safety training for healthcare providers, and the establishment of regular monitoring and medication error reporting systems are all required to reduce the occurrence of medication errors.

Author contribution statement

Agegnehu Bante; Abera Mersha; Zeleke Aschalew; Aklilu Ayele: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.

Data availability statement

Data will be made available on request.

Declaration of interest’s statement

The authors declare no competing interests.

Acknowledgments

References