George D, Supramaniam ND, Abd Hamid SQ, Hassali MA, Lim WY, Hss AS.

Effectiveness of a pharmacist-led quality

improvement program to reduce medication errors during hospital discharge. Pharmacy Practice 2019 Jul-Sep;17(3):1501.
https://doi.org/10.18549/PharmPract.2019.3.1501

Original Research
Effectiveness of a pharmacist-led quality improvement
program to reduce medication errors during
hospital discharge
Doris GEORGE , Nirmala D. SUPRAMANIAM , Siti Q. ABD HAMID , Mohamad A. HASSALI ,
Wei-Yin LIM , Amar-Singh HSS .
Received (first version): 20-Mar-2019 Accepted: 5-Aug-2019 Published online: 21-Aug-2019

Abstract
Background: Patients requiring medications during discharge are at risk of discharge medication errors that potentially cause
readmission due to medication-related events.
Objective: The objective of this study was to develop interventions to reduce percentage of patients with one or more medication
errors during discharge.
Methods: A pharmacist-led quality improvement (QI) program over 6 months was conducted in medical wards at a tertiary public
Article distributed under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported (CC BY-NC-ND 3.0) license

hospital. Percentage of patients discharge with one or more medication errors was reviewed in the pre-intervention and four main
improvements were developed: increase the ratio of pharmacist to patient, prioritize discharge prescription order within office hours,
complete discharge medication reconciliation by ward pharmacist, set up a Centralized Discharge Medication Pre-packing Unit.
Percentage of patients with one or more medication errors in both pre- and post-intervention phase were monitored using process
control chart.
Results: With the implementation of the QI program, the percentage of patients with one or more medication errors during discharge
that were corrected by pharmacists significantly increased from 77.6% to 95.9% (p<0.001). Percentage of patients with one or more
clinically significant error was similar in both pre and post-QI with an average of 24.8%.
Conclusions: Increasing ratio of pharmacist to patient to complete discharge medication reconciliation during discharge significantly
recorded a reduction in the percentage of patients with one or more medication errors.

Keywords
Patient Discharge; Medication Reconciliation; Medication Errors; Prescriptions; Pharmacy Service, Hospital; Pharmacists; Quality
Assurance, Health Care; Malaysia

INTRODUCTION defined as admission medication reconciliation.1

Information is obtained through various sources: patient,
Patients admitted to hospital undergo various
caregiver, hospital records, health-care providers and
investigations, procedures and prescribed medications to
community pharmacists.
manage their medical conditions. Prescribing medications
during admission require initiating medication(s) for the During discharge, an accurate patients’ discharge
current medical condition(s) as well as continuing patients’ medication list is prepared based on comparison of
pre-existing medications for any underlying medical admission medication reconciliation list, medications
conditions. In some cases, the patients’ pre-existing prescribed in the ward, and medications planned at
medications, could be the reason for admission and discharge with the agreement of physicians, patients and
discontinuation or dosing adjustment of the offending caregivers. These changes have to be documented and
medications may be required. A formal process to obtain communicated to patients or caregivers. These processes
an accurate and complete list of medications that patient are collectively defined as discharge medication
was previously taking (including prescription medications, reconciliation.1
over-the-counter, supplements and herbal preparations) is
Medication reconciliation is a highly complex and time-
consuming process, demanding significant skills. The
Doris GEORGE. Pharmacy Department, Raja Permaisuri Bainun American Society of Health-System Pharmacists (ASHP)
Hospital; &. Discipline of Social & Administrative Pharmacy, School recommends pharmacists who are uniquely qualified, to
of Pharmaceutical Sciences, Universiti Sains Malaysia. Penang
(Malaysia). doris.moh.gov@gmail.com
lead, establish and maintain effective medication
Nirmala Devi SUPRAMANIAM. Pharmacy Department, Raja reconciliation processes in hospitals.2 In additional,
Permaisuri Bainun Hospital. Perak (Malaysia). pharmacists are able to communicate with community
nmala_15@yahoo.com
Siti Qurasyiah ABD HAMID. Pharmacy Department, Raja pharmacist counterparts to obtain and relay relevant
Permaisuri Bainun Hospital. Perak (Malaysia). medication details.3
qurasyiah@gmail.com
Mohamad Azmi HASSALI. Discipline of Social & Administrative Medication reconciliation lists are used to compare with
Pharmacy, School of Pharmaceutical Sciences, Universiti Sains
Malaysia. Penang (Malaysia). azmihassali@gmail.com
discharge prescription orders either in same health-care
Wei-Yin LIM. Center for Clinical Epidemiology, Institute for Clinical facilities, primary care physicians or community
Research, National Institutes of Health, Ministry of Health. Selangor pharmacies; and any inconsistencies between both lists are
(Malaysia). amanda.limwy.crc@gmail.com
Amar-Singh HSS. Pediatric Department, Raja Permaisuri Bainun identified as medication discrepancies. Discrepancies that
Hospital, Ministry of Health. Perak (Malaysia). amarhss@gmail.com are without any clinical rationale or without the attending

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George D, Supramaniam ND, Abd Hamid SQ, Hassali MA, Lim WY, Hss AS. Effectiveness of a pharmacist-led quality improvement
program to reduce medication errors during hospital discharge. Pharmacy Practice 2019 Jul-Sep;17(3):1501.
https://doi.org/10.18549/PharmPract.2019.3.1501

physicians consciously altering the therapy are defined as Discharge prescription are ordered by house officers
unintentional discrepancies; which are categorized as (qualified doctor practising under supervision after first
medication errors.4,5 Such medication errors among adult year of graduation) through electronic ordering system. If
patients discharged from the general medical wards ranged discharge prescriptions are ordered after officer hours,
from 23% to 70%.6-14 The most common medication error patients collected their medications from the hospital
at discharge was found to be unintentional omission of outpatient pharmacy.
medications.10,11,13 Medication review during patient’s
Medication error detection
home visit by pharmacists within 2 week of hospital
discharge revealed variety of medication issues such as Discharge medication reconciliation list is compared with
untreated indication, improper doses and medications with prescription order by ward pharmacist either on the same
no indication.15 It has been reported that unintentional day of patient discharge (prescription ordered within office
medication changes or unintentional medication omission hours) or the following morning (prescription ordered after
that are not correct during discharge contributed office hours). Any discrepancies detected by ward
readmission in adult patients.16,17. Unintentional omission pharmacist are discussed with the attending physician in
of insulin human isophane during discharge caused the ward and decided if the discrepancies are intended or
patient’s blood sugar rise to 517 mg/dL and vomiting at unintended.5 Unintended discrepancies are recorded by
nursing home which resolved after restarting insulin ward pharmacist as medication error in the data collection
therapy.13 Unintentional increase of clonazepam dose; sheet provided. Medication errors that are detected the
caused lethargy in patient and subsequently fall at nursing following morning by ward pharmacist are non-intercepted
home.13 medication. Non-intercepted errors are errors that
reached patient.18 Type of medication errors (wrong
Hence, the aim of this study was to modulate interventions
dosing, wrong drug, unintentional omission or addition of
to reduce percentage of patients with one or more
medication) for this study are adapted based on work by
medication errors during discharge.
Pippins et al. (2008) and classified as shown in Online
appendix 1. Although the research pharmacist retrieved
METHODS information on the prescription medications, over-the-
counter medications as well as supplements and herbal
Study design and setting
preparations, this study only focused on prescription
We conducted a prospective, quasi-experimental, pre-post medicines only for the purpose of medication error
intervention study to evaluate the effectiveness of a identification.
pharmacist-led quality improvement (QI) program for
All prescribing errors detected were reviewed for clinical
reducing medication errors during hospital discharge.
significance by two senior pharmacists and a medical
This study was conducted in nine adult general medical specialist independently. Errors were categorized into two
wards at a 990-bedded tertiary care public hospital in Ipoh, categories: clinically significant or non-clinically significant.
Malaysia. These wards have a total of 276 beds with Clinically significant errors are errors that would cause
multiple medical specialities such as cardiology, detrimental effect to patients’ health, treatment delay and
nephrology, neurology, haematology, endocrinology and ineffective treatment if not detected and corrected before
pulmonology. reaching patients (Code E – I). The coding are based on
National Coordinating Council for Medication Error
Prior to the study, each medical ward has one ward
Reporting and Prevention (NCC MERP).19 Any differences in
pharmacist assigned to work during office hours (8.00 am
coding were discussed and a consensus agreement was
to 5.00 pm) on weekdays. The ward pharmacists’ core
reached among the three reviewers.
responsibilities are to perform medication reconciliation at
admission, review medication therapy, prevent medication Improvement team
errors and participate in clinical ward rounds. During daily
The pharmacy department initiated this QI program. The
medication review, all medications prescribed in ward are
improvement team consisted of the manager of medical
reviewed for correct doses, formulations, route of
department, manager of the pharmacy department,
administrations, indications, contraindications,
physicians and pharmacists. A key driver diagram was
compatibilities, side-effects, interactions, efficacy,
developed as depicted in Figure 1.
monitoring, adherence issues and evidence-based
treatment. Medication-related issues identified as Phase 1: Pre-Intervention
mentioned above are discussed with attending physicians
during ward rounds to optimize medication therapy based This study was conducted over a period of 9 months in
on an individual patient’s condition. Ward pharmacists three phases. In the first phase, pre-intervention data on
perform discharge medication reconciliation during prescribing errors during hospital discharge were collected
discharge; comparing admission medication reconciliation on 4 consecutive weekdays (Mondays to Thursdays) on
lists, ward medications are compared and discharge plans. selected weeks in each month over a 3-months period
Patient-related issues (adherence, social support, (July, August and September 2017) as decided by the
preferences etc.) are identified. Attending physicians are researchers. We selected the study points of 4 consecutive
consulted and the discharge medication reconciliation list is weekdays for data collection based on availability of all
obtained. Bedside discharge medication counselling is done nine-ward pharmacists and no presence of public holidays
to communicate medication changes and other medication- in the selected week.
related information.

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George D, Supramaniam ND, Abd Hamid SQ, Hassali MA, Lim WY, Hss AS. Effectiveness of a pharmacist-led quality improvement
program to reduce medication errors during hospital discharge. Pharmacy Practice 2019 Jul-Sep;17(3):1501.
https://doi.org/10.18549/PharmPract.2019.3.1501

Global Aim Change Strategies

All changes were during office
Ensure hours only
discharge
patients receives Reduce ratio of pharmacist to
complete and patients from 1:40 to 1:20.
Primary Drivers
accurate
discharge
Ward pharmacist Prioritizing ordering
medications.
available at ward for discharge prescriptions
discharge medication during office hours
reconciliation.

Specific Aim Centralized Discharge

Discharge Medication Pre-packing Unit.
Reduce prescriptions
prescribing prescribed within
error among office hours Discharge medications
patients delivered to ward pharmacist.
discharged
from general
medical wards. Medication
. reconciliation by ward
pharmacist Discharge prescription
compared with the medication
reconciliation list.
Easy pickup of
discharge
medications. Bedside discharge
medication counselling by
ward pharmacists.

Figure 1. Key driver diagram

office hours are recorded as non-intercepted errors; hence

Discharge prescriptions from medical wards that are
patients are contacted to provide correct medications and
received by ward pharmacists or outpatient pharmacists by
prescriptions. All medication errors detected are corrected
10 pm weekdays were printed and collected for the
in the electronic ordering system by ward pharmacists.
purpose of this study. Discharge prescriptions which were
not collected on the same date of prescriptions order date All nine ward pharmacists that are involved in data
were excluded. collection had at least a minimum of 3 years of working
experience in the medical wards.
Discharge prescriptions after office hours are screened by
outpatient pharmacists in the routine manner for correct An instructive letter from the Chief Pharmacist was issued
dosing regime based on standard dosing references. Errors to the ward pharmacists and outpatient pharmacists during
detected are corrected subsequently either by the each point of study as a reminder to collect discharge
prescribers, or by the pharmacists, who would have prescriptions as proposed above. All pharmacists involved
contacted the prescribers (adhering to standard protocol), in the data collection were briefed for a maximum of 30
in the electronic ordering system. Errors detected were minutes per session before each point of data collection.
highlighted using red ink ball pen on printed prescriptions.
Phase 2: Quality Improvement
Discharge prescriptions during office hours and after hours
Phase 2, the intervention phase was conducted over three-
are compared with the discharge reconciliation medication
months (October to December 2017) and no data was
list by ward pharmacists. If the ward pharmacists detected
collected during this phase. Pre-intervention data of
any unintentional discrepancies, it was discussed with the
medication errors at discharge were presented to
attending physician in the ward. Unintentional
managers of both the pharmacy and medical department.
discrepancies are recorded as medication errors.
Subsequently, the following improvement measures were
Unintentional discrepancies in discharge prescription after
implemented:

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George D, Supramaniam ND, Abd Hamid SQ, Hassali MA, Lim WY, Hss AS. Effectiveness of a pharmacist-led quality improvement
program to reduce medication errors during hospital discharge. Pharmacy Practice 2019 Jul-Sep;17(3):1501.
https://doi.org/10.18549/PharmPract.2019.3.1501

1. The number of ward pharmacists was increased in all The sampling size was calculated by setting a power of 90%
medical wards from one to two to accommodate a and significance level of 5% for independent cases using PS
ratio of pharmacist to patients of 1 to 15-20. Power and Sample Size Calculation Version 3.0. Baseline
error was assumed at a rate of 40% based on a pilot study
2. House officers were instructed to prioritize ordering
conducted in this hospital for a month prior this study.
discharge prescriptions within office hours in order for
Assuming that with a 15% decrease in discharge
the ward pharmacists to complete discharge
prescription error post-intervention, given various
medication reconciliation process.
interventions in literature resulted in 20 – 40% of absolute
3. Ward pharmacists performed discharge medication reduction in rates of error in discharge prescriptions, a total
reconciliation (compared all prescriptions ordered by of 203 prescriptions were required in each pre and post-
house officers against the discharge medication intervention phase.20-22
reconciliation list) and provide bedside discharge
Statistical analysis
medication counselling. In the past, this was an ad hoc
activity where only about 5-10% of the ward The data collected at the end of each week was entered
pharmacists’ total working time per day was allocated into Stata V.13 Statistical Software for analysis. Categorical
for this activity. As a quality improvement strategy, this data were presented as frequency with percentages, while
was emphasized as part of the ward pharmacists’ continuous data were summarized as means with standard
routine responsibilities. deviations (SD) if approximately normally distributed, or
median and interquartile ranges (IQR) otherwise.
4. A Centralized Discharge Medication Pre-packing Unit
was set up to facilitate packing of discharge medication The statistical process control (SPC) chart was employed to
to enable ward pharmacists to provide bedside illustrate the impact of the QI program on the primary
dispensing and medication counselling. In the past, outcomes.23-26 This method of evaluating the effectiveness
respective ward pharmacists had to leave the ward to of interventions to reduce prescribing errors in the primary
return to the pharmacy to pack discharge medications. care settings provided valuable information to managers
In this study, staffs at the Centralized Discharge for decision-making.27 The p-chart (p stands for percentage)
Medication Pre-packing Unit packed the discharge was chosen to chart the percentage of patients with
medication based on discharge prescriptions ordered prescribing error as the outcome measures were binary
in the system and delivered to the wards where the QI (error versus no error) and the number of discharged
program was implemented. patients (sample size) at each point was not constant. To
enable the comparison of primary outcome measures
Phase 3: Post-Intervention
between pre- and post-intervention phases, we calculated
In phase 3, similar to the pre-intervention data collection, the mean percentage error for each phase using the total
post-intervention data collection was done for another 3 number of patients with error prescriptions and as the
months (January to March 2018). Outpatient pharmacists nominators and total discharge patients as the
on duty were briefed before each point of data collection. denominators. The upper control limit (UCL) and lower
The same nine designated ward pharmacists in the pre- control limit (LCL) denoted the boundaries within which
intervention data collection were involved in the data 99% of the data points will be found when the limits are set
collection process in the wards. at a distance of 3 sigma [3 SDs] from the mean. Changes in
the mean process error between phases were evaluated
Study outcomes using the Chi-square test. Data with two-sided p-value of
The primary outcomes of the study were the percentage of less than 0.05 (p<0.05) was considered statistically
discharged patients with: 1) medication error, 2) clinically significant.
significant medication error, and 3) non-intercepted Ethical considerations
medication error. The denominator for the primary
outcomes was the total number of patients that were The study was registered with the National Medical
discharged from the nine medical wards as shown in the Research Registry (NMRR) [NMRR-17-1628-36539] and
Equation 1-3. code of ethics approval was obtained from Medical
Research and Ethic Committee (MREC).
Equation 1: Percentage of patients discharged with
medication errors Attending physicians were notified of non-intercepted
prescribing errors. The ward pharmacist and attending
physician discuss each of these prescribing errors. Patients
are contacted to provide correct medications and
Equation 2: Percentage of patients discharged with prescriptions. Decision was made not to contact patient by
clinically significant medication errors attending physician when error did not pose any harm to
patient. Examples of such errors was oral prednisolone was
prescribed 4 days instead of 3 days for a patient with acute
Equation 3: Percentage of patients discharged with non- exacerbation of asthma. In another error, inhaler
intercepted medication errors beclomethasone was omitted from prescription order but
the device was already supplied to patients during device
counselling in hospital and furthermore patient has a
doctor’s follow-up appointment in two weeks. All non-
intercepted errors were corrected in the electronic system.

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George D, Supramaniam ND, Abd Hamid SQ, Hassali MA, Lim WY, Hss AS. Effectiveness of a pharmacist-led quality improvement
program to reduce medication errors during hospital discharge. Pharmacy Practice 2019 Jul-Sep;17(3):1501.
https://doi.org/10.18549/PharmPract.2019.3.1501

Table 1. Characteristics of patients, prescribers, and prescriptions during the study

Characteristics Pre-Intervention Phase Post-Intervention Phase p-value
Total patients, n 505 482
Gender of patients, n (%) 0.3
Male 294 (58.2) 264 (54.8)
Female 211 (41.8) 218 (45.2)
Age of patients (in years), mean (SD) 59.9 (16.2) 58.9 (17.6) 0.4
Diagnosis on Prescription, n (%)
Cardiovascular Diseases 176 (34.9) 146 (30.2)
Infection 44 (8.7) 41 (8.5)
Renal Diseases 41 (8.1) 39 (8.1)
Lung Infections 37 (7.3) 44 (9.1)
Stroke 30 (5.9) 25 (5.2)
Acute Exacerbations of BA or COPD 23 (4.6) 17 (3.5)
Diabetes Related Admissions 22 (4.4) 30 (6.2)
Blood Disorders 22 (4.4) 19 (3.9)
Seizures 17 (3.4) 23 (4.8)
Cancers 10 (2.0) 11 (2.3)
Liver Diseases 10 (2.0) 9 (1.9)
Electrolyte Imbalances 9 (1.8) 13 (2.7)
Adverse Drug Events 7 (1.4) 5 (1.0)
Others 5 (1.0) 8 (1.7)
Unclear 46 (9.1) 24 (5.0)
Missing 6 (1.2) 28 (5.8)
Prescriber category, n (%)
House Officer 465 (92.1%) 440 (91.3%) 0.6
Medical Officer 40 (7.9%) 42 (8.7%)
No. of medications, mean (SD) 6.5 (3.2) 6.6 (3.5) 0.5
Duration of prescription, n (%) 0.8
One month or more 423 (83.8) 406 (84.2)
Less than a month 82 (16.2) 76 (15.8)
Time of prescription order (%) < 0.001
Office hours 214 (42.4) 382 (79.3)
After officer hours 291 (57.6) 100 (20.7)
SD - standard deviation, BA – bronchial asthma, COPD – chronic obstructive pulmonary disease

One researcher followed-up with ward pharmacists one or more errors was 32.2%, but could be as high as
regarding decision made regarding all non-intercepted 42.7% or as low as 20.0%, which represented the variation
errors. The prescriptions collected were labelled according found in errors from discharge prescriptions (Figure 3A).
to their prescription dates and stored with rest of the During the entire six months study period, only common
prescriptions received by the pharmacy for 2 years, based variations were observed and therefore, the process was
on instructions from the Ministry of Health Malaysia (Ref: considered stable and predictable. The process remained
ANM.600- 1/24/4/8 dated 3rd October 2012). Stata under similar conditions after the implementation of the QI
database and excel spreadsheets did not include any program for a period of three months. The mean
unique identifiable details for the involved patients or percentage of error during the pre-intervention and post-
prescribers. intervention phases were not dissimilar (29.7% vs. 34.9%,
p=0.08). Same patterns were observed in the percentage of
patients with one or more clinically significant errors
RESULTS
(Figure 3B). The process was stable and predictable,
During the study period, 1014 patients were discharged exhibiting only common cause variation, where an average
from nine general medical wards. Of these, 27 patients 24.8% of patients experienced clinically significant errors
were excluded as their discharge medications were not (ranged between 15.2% and 34.4%). The mean percentage
collected on the day of discharge. Therefore, 987 patients of patients with clinically significant errors during the pre-
were included in the final analysis with 505 patients in the intervention and post-intervention phases were similar
pre-intervention phase and 482 patients in the post- (23.8% vs. 25.9%, p=0.40). Figure 2C illustrates the
intervention phase. The characteristics of patients, percentage of patients with one or more non-intercepted
prescribers, and prescriptions during the study period are errors. The baseline reflects common cause variation with a
summarised in Table 1. All characteristics were similar in process mean of 22.4%. The team began implementing the
both phases, except for the percentage of discharge QI program at the end of the pre-intervention phase of
prescriptions that were ordered during office hours, which three months; during which no data were collected
increased as a result of implementing the second Subsequently, the plotted data for the post-intervention
component of the QI program. phase after implementation of the QI program strongly
suggested that the percentage of patients with one or more
Figure 2 illustrates the impact of the QI program on
non-intercepted errors progressed in a positive downward
percentage of patients with medication errors during
manner, culminating in a special cause (8 consecutive
hospital discharge. Study phases were directly annotated
points below the baseline process mean). This special cause
onto charts. On average, the percentage of patients with
reflected the introduction of the QI program into a process

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George D, Supramaniam ND, Abd Hamid SQ, Hassali MA, Lim WY, Hss AS. Effectiveness of a pharmacist-led quality improvement
program to reduce medication errors during hospital discharge. Pharmacy Practice 2019 Jul-Sep;17(3):1501.
https://doi.org/10.18549/PharmPract.2019.3.1501

in transition, resulting in a reduction in the mean The common medication classes that were omitted were
percentage of non-intercepted errors from 22.4% to 4.1% medications classified under the cardiovascular system, 57
(p<0.001), and tighter control limits (indicating less errors (36%) followed by the alimentary tract and
variation in the process). metabolism, 42 errors (27%) and blood and blood forming
organ, 20 errors (13%). Medications that was most often
Patients had a median of 7 (interquartile range, IQR 4, 9)
omitted were sublingual glycerine trinitrate (in 15
medications in their discharge prescriptions. Total
prescriptions), atorvastatin (in 11 prescriptions), and
medications prescribed in the pre-intervention was 3264
clopidogrel (in 8 prescriptions) while various types of
and in post-intervention was 3192. Extend of error per
insulins, calcium carbonate and pantoprazole were omitted
patient ranged from 1 to 6. With the implementation of QI
each in 7 prescriptions. Medication classes that were most
program, total non-intercepted errors reduced significantly
often involved in other than omission of medications were
from 176 (5.4%) to 28 (0.9%) (p<0.001). Most of
alimentary tract and metabolism, and cardiovascular
discrepancies detected, 99.6% (512/514), by ward
systems, involving 104 errors (29%), and 86 errors (24%)
pharmacists was accepted by the attending physicians as
respectively. Various types of insulins 23 errors (6%),
unintentional discrepancies and as medication errors. Eight
frusemide 21 errors (6%), acetylsalicylic acid 19 errors (5%),
of the errors were not corrected in the electronic ordering
metformin errors (5%) and calcium carbonate 12 errors
system as errors was considered not clinically significant by
(3%) topped the list of medications of other than omission
attending physicians and all of it involved wrong duration
errors. A complete list of medications according to class
of medications. Some examples of clinically significant
and medications involved in the discharge prescribing
medication errors were summarized in Online appendix 2.
errors, were sub-categorised as shown in Online appendix 3
Types of errors are summarized in Table 2. In both pre- and Online appendix 4 respectively.
intervention and post-intervention phase, the most
common type of errors was omission of medication, wrong
DISCUSSION
dose and wrong frequencies. All types of errors were
similar in both phases but wrong duration significantly The intervention program successfully attained high
increased after the introduction of the QI program. percentage of patients with medication errors that was

Table 2. Discharge Prescribing Errors by Sub–category Pre and Post-Quality Improvement Program. Total medication prescribed:
Pre, N=3264 and Post, N=3192
Type of Errors errors (%) Pre Post p-value
Total Error 231 (7.1) 281 (8.8) 0.03
Total Error Per Patient
None 355 (70.3) 314 (65.2)
1 103 (20.4) 88 (18.2)
2 29 (5.7) 57 (11.8)
3 11 (2.2) 13 (2.7)
4 2 (0.4) 10 (2.1)
5 1 (0.2) 0
6 4 (0.8) 0
Total Clinically Significant Errors 172 (5.3) 182 (5.7) 0.1
Clinically Significant Errors Per Patient 0.4
None 385 (76.2) 357 (74.1)
1 89 (17.6) 88 (31.3)
2 19 (3.8) 34 (7.05)
3 7 (1.4) 7 (1.5)
4 2 (0.4) 3 (0.6)
5 2 (0.4) 0
6 1 (0.2) 0
Non-Intercepted Errors 176 (5.4) 28 (0.9) < 0.001
None 392 (77.6) 465 (95.9)
1 79 (15.6) 15 (3.1)
2 19 (3.8) 3 (0.6)
3 9 (1.8) 1 (0.2)
4 2 (0.4) 1 (0.2)
6 4 (0.8) 0
Types of Errors
Omission of Medication 91 (39.4) 69 (24.6) 0.2
Wrong Dose 64 (27.7) 84 (29.9) 0.07
Wrong Frequency 28 (12.1) 44 (15.7) 0.05
Wrong Duration 10 (4.3) 48 (17.1) <0.001
Medication Not Indicated 20 (8.7) 6 (2.1) 0.1
Wrong Formulation 9 (3.9) 13 (4.6) 0.3
Wrong Drug 6 (2.6) 9 (3.2) 0.4
Polypharmacy 1 (0.4) 3 (1.1) 0.3
Wrong Instruction 0 3 (1.1) 0.1
Wrong Route 1 (0.4) 2 (0.7) 0.5
Omission of Instruction 1 (0.4) 0 0.9

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George D, Supramaniam ND, Abd Hamid SQ, Hassali MA, Lim WY, Hss AS. Effectiveness of a pharmacist-led quality improvement
program to reduce medication errors during hospital discharge. Pharmacy Practice 2019 Jul-Sep;17(3):1501.
https://doi.org/10.18549/PharmPract.2019.3.1501

Figure 2. p-chart illustrating serial percentages in pre-intervention phase (July to September 2017) and post-intervention
phase (January to March 2018) of patients discharged with one or more medication errors (A), clinically significant
medication errors (B) and non-intercepted medication errors (C).

intercepted and corrected at discharge. The major medical discharge summaries, reduced at least one
component of this QI program was the complete medication error by an absolute risk reduction of 47%.20
reconciliation of medications at admission to discharge
In a recent systematic review, during discharge medication
including bedside discharge medication counseling by ward
reconciliation; median clinical significant error
pharmacists. In various studies; pharmacists play an
(discrepancies) identified was 34% (IQR 28% - 49%).36 The
important role in medication error reduction through
median percentage of patients with one or more clinically
discharge medication reconciliation.28-35 A recent
significant errors was 45% (IQR 31% - 56%).36 Average
randomized control trial which included pharmacists to
percentage of patients in this study with one or more
completed the medication management plan in the
clinically significant errors was 24.8% and accounted to
5.5% of the total medication errors identified during

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George D, Supramaniam ND, Abd Hamid SQ, Hassali MA, Lim WY, Hss AS. Effectiveness of a pharmacist-led quality improvement
program to reduce medication errors during hospital discharge. Pharmacy Practice 2019 Jul-Sep;17(3):1501.
https://doi.org/10.18549/PharmPract.2019.3.1501

discharge. The low percentages could have been who are involved in prescribing discharge medication but
contributed to medications in wards were reviewed by rarely discuss these plans with their specialists or medical
pharmacist daily in this setting and errors such as dosing officers, has also shown a reduction overall errors in
adjustments, contraindications and polypharmacy were discharge prescription order.39,40
already intervened much earlier before discharge.
Implications and future research
Pharmacists detected significantly higher errors involving
incorrect duration in the pre-QI phase, we hypothesized The discharge medication reconciliation service by ward
that the attentiveness of ward pharmacist increased with pharmacists continues at the medical wards in this hospital.
the implementation of the QI program. Discharge medication reconciliation service by ward
pharmacists have been expanded to two pediatric wards
The most common error, identified during discharge
and two surgical wards.
medication reconciliation in this study was omission of
medications, 160 (31.2%). This result is in line with other Sustainability of this service can be tested using similar
studies, that reported, omission of medications as the most method use in the study in the future. Future study can
common type of medication errors during discharge which also include other components such as training, feedback,
ranged from 85% to 23%.7,10,12 allowing other than house officer to order discharge
medication can be used to explore overall reduction in
Limitations
discharge medication errors. Other areas of research are to
The results of this study should be viewed in the light of explore (i) implication of medication error in discharge
some limitations. The study was conducted only on medication on patients’ outcome and (ii) cost implication of
weekdays, therefore excluding the percentage of pharmacist to prevent clinically significant medication
medication errors on weekends, whereby, staffing of errors at discharge.
physicians and medical officers are lower.
Percentage of discharge patients prescribed with at least ACKNOWLEDGMENTS
one or more errors remained similar and consistent as
We would like to thank the Director General of Health
other components that affect prescribing of discharge
Malaysia for his approval to publish this work. Our heartfelt
medications were not addressed in this QI program. House
appreciation to all pharmacists who participated in
officers who are responsible for ordering discharge
collecting the prescribing errors in discharge prescriptions
medications are scheduled on a 4-weekly rotation to each
as required by the study protocol. We also like to convey
medical ward. House officers only require to prioritize
our appreciation to our chief pharmacist, Madam Norma
ordering discharge and not involved in any other
Abdullah and head of medical department, Dr Letchuman
component of the QI program. In order to improve overall
Ramanathan, in support of this study.
medication error, house officers should also be an
important part of the QI component.
CONFLICT OF INTEREST
Interventions that have not been implemented in our
setting but have been implemented elsewhere proven to None declared.
have reduced prescribing error at discharge, such as
planning the discharge medications during ward rounds
FUNDING
and computerized discharge assistance to ease prescribing
discharge medications.21,22,37,38 Giving constructive None.
feedback and training on a regular basis for house officers,

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