Prevalence and types of Medication Errors in In-patient settings: A PCNE-Based Study with Pharmacist-Led Intervention at DHQ Hospital KDA Kohat

Israr Hussain^1*, Rafiq Ahmad², Muhammad Huzaifa

^1,2,3Department of Pharmacy Kohat University if Science and Technology, Kohat-26000 Khyber Pakhtunkhwa, Pakistan

*Corresponding Author Israr Hussain, Department of Pharmacy Kohat University if Science and Technology, Kohat-26000 Khyber Pakhtunkhwa, Pakistan, E-mail: hisrar568@gmail.com

Abstract

Background: Medication errors continue to be a major concern in healthcare, often leading to serious consequences for the well-being of those receiving treatment, yet preventable, particularly within hospital in-patient settings where patients often receive complex therapeutic regimens. These errors can occur during any stage of the medication use process prescribing, transcribing, dispensing, administration, or monitoring and may result in adverse drug events, prolonged hospitalization, increased healthcare costs, and even patient mortality. Methodology: This study aimed to assess the prevalence and types of medication errors using the Pharmaceutical Care Network Europe (PCNE) classification system, and to evaluate the effectiveness of pharmacistled interventions in reducing such errors among in-patients at DHQ Hospital, KDA Kohat, Kohat. A prospective observational study was conducted over a period of one year in the Critical Care Unit (CCU), Medical, and Surgical wards of DHQ Hospital, KDA Kohat. Data were collected from 112 prescriptions. Each prescription was analyzed using PCNE classification system version 9.1 to identify medication errors and their underlying causes. All interventions by clinical pharmacists were documented and categorized accordingly. Results: Among these 112 prescriptions reviewed, 69 medication errors were identified. The most frequent problems were associated with inappropriate drug selection (P1) and incorrect dose selection (P3). The primary causes included lack of drug knowledge (C1), failure to adjust doses in renal impairment (C7), and prescribing without a valid indication (C5). Pharmacists intervened in 10 cases, with common interventions including notifying the prescriber, adjusting dosages, and therapeutic substitutions. Notably, approximately 83.3% of these interventions were accepted by the prescribers. Conclusion: The findings demonstrate that medication errors are notably prevalent in in-patient hospital settings, especially in the CCU, Medical, and Surgical wards. Clinical pharmacists significantly contributed to error reduction through structured interventions. Incorporating routine pharmacist-led medication reviews may enhance patient safety and promote rational medication use in healthcare institutions.