Impact of Knowledge, Attitude and Practice on Medication errors and Safety Improvement in Pharmacy Departments of King Saud University Medical City Riyadh Saudi Arabia

The current study was premeditated to evaluate the attitude, knowledge and practice of the pharmacy employees (including interns and trainees) dealing with medical practice towards medical errors and adverse drug reaction reports. Methods:The study is a quantitative, descriptive, cross-sectional one with the influence of medication-error reporting, focused on pharmacy department of King Saud University Medical City, Riyadh,

Poor patient safety in health systems through medical error reporting is the third most common cause of death globally, behind cardiovascular diseases and cancer, it is a reversible action as being the main responsibility of the health care provider for the patient safety, and can be rectified and avoided. The healthcare organizations need to encourage reporting of the medical related errors and implement clear policies and guidelines which can encourage the healthcare provider to safeguard the interest of the patients. The safety system needs not just to be in place, but to be successful. 1,2,3,4,5 Recently Ahmed 6 et al., have reported that the common medical errors result from incomplete instructions, incorrect dosage, and incorrect route of administration, diagnosis errors, and labelling errors. The perceived causes of these medical errors include high workload, lack of support systems, stress, medical negligence, inadequate training, miscommunication, poor collaboration, and non-adherence to safety guidelines among the healthcare professionals based on a study conducted in a Kuwait tertiary hospital. A similar work has reported seven perceived reasons for medical errors, namely system reason, nurses' staffing, physician communication, medication packaging, transcription, and pharmacy process. The study recommended the development of active quality assurance systems in all health care environments, concerning medications and drug administration 4. Medication errors occur broadly on various steps that includes dispensing, transcribing, prescribing and administration. It has decreased due to use of computerized physician order administration than hand written prescription (HWP). Numerous approaches have been suggested in detection and of the occurrence of medical errors and the way of reducing it. Adverse drug reaction is the common approach used and mostly employed in high risk industries such as hospitals. 7, 8 Alsulami 9 et al., Hammoudi 10 et al., and Alshahrani 11 et al., have surveyed information, frames of mind and practices towards the detailing of prescription mistakes among wellbeing professionals at some hospitals of Saudi Arabia to find remedies to ward off such medical errors. The investigations led by Stewart 12 et al., planned to measure and disclose conduct determinants identifying with errors announcing of human services experts in Qatar, as a premise of creating intercessions to upgrade the adequacy and proficiency of mistake revealing. Quantitative results showed that while these were issues for all medicinal services experts, those more youthful and less experienced were generally concerned.
George 13 et al., created mediations to decrease level of patients with at least one medicine error during release. A drug specialist drove quality improvement (QI) program more than a half year directed in medicinal wards at a tertiary open emergency clinic. With the usage of the QI program, the level of patients with at least one prescription error during release that was remedied by drug specialists fundamentally expanded from 77.6% to 95.9%. Assiri 14 et al., utilized electronic wellbeing record information. Many studies have investigated the burden of medical errors in healthcare systems throughout the world 15 , which significantly increase treatment costs and hospitalization periods, aside from increasing patient rates of mortality and morbidity in some situations 16 . However, there is insufficient data about medical error reporting and actions taken thereof, in Saudi Arabia, and in Middle Eastern countries generally. One report indicates that there were 1,356 cases reported in 2013 17 , but the true prevalence is undoubtedly far higher than the number of reported instances. 18 It is essential to understand the difficulties associated with disclosing medical error mishaps in Saudi Arabia in order to avoid other potential errors and near misses that could adversely affect patients. This study helps filling this gap in knowledge and contributes towards professional discourse and policy decision making to improve medication safety in King Saud University Medical City (KSUMC) based in the Capital of Saudi Arabia, Riyadh. It is one of the largest university medical cities around the Kingdom. The objective of the present research was to assess the current status of the medication error reporting program and evaluate the cultural impact of patient safety initiatives and interventions. It also addresses to identify the strengths and weakness areas for patient safety culture improvement in a bid to raise the staff awareness about the patient and medication safety.

Material and Methods
Study Design and Setting: The observational cross-sectional study was conducted to assess the knowledge, attitude and practices about medication errors and patient safety among the pharmacy professionals in King Saud University Medical City, (KSUMC), Riyadh, Saudi Arabia. Necessary Ethical approval was obtained from the Institutional review board (IRB) Ref. No. 19/0143/14RB. The data were collected between December 2019 and March 2020. The inclusion criteria included those who were available and willing to participate were approached and asked to fill out questionnaires whereas the exclusion criteria included those individuals who couldn't complete the questionnaire for any reason The community pharmacy survey questionnaire, adapted from AHRQ, USA was distributed to the participating pharmacists and clinical pharmacists and were requested to complete the 5 point Likertscale survey, ranging from 'strongly disagree' to `strongly agree'. The questionnaire consisted of 2 sections namely demographic characteristics whereas the second section included 4 parts with a total of 38 questions with a total of working in pharmacy department, ccommunication and work pace, patient safety and response to mistakes as well as documenting mistakes. Before executing the actual study, necessary piloting was done on 60 community pharmacists with Reliability statistics (Cronbach's alpha = 0.86) suggesting a good internal consistency. A total of 496 staff using convenient sampling was used for the selection of participants. The actual sample size estimated was 150 using the Thompson equation with an error margin of 5%, 95% confidence interval and a response distribution of 50% (19) . The actual cohort which participated in the study was 167.
We assured the respondents that anonymity and confidentiality will be upheld during the entire process.
Statistical analysis: SPSS version 22 was used to evaluate the results (IBM Corp., Armonk, NY, USA). A statistically relevant value of p < 0.05 was calculated. The categorical variables were evaluated with the Chi-square test.

results and discussion
A total of 167 pharmacists from the King Saud University Medical City in Riyadh participated in the study with a response rate of 99%. The demographic data was represented in Table 1,showing working characteristics of the respondents in terms of years of work in pharmacy department, number of working hours/week and their work position/designation. The data showed that 15 % of the respondents worked for less than 6 months, whereas 5.4 % worked for more than 6 months and less than 1 year. Similarly, 17.4 % worked from 1-3 years, 32.3 % worked between 3-6 years, 16.2 % between 6-12 years, finally 13.8 % worked for 12 and more years. In terms of working hours, 6 % out of the total sample size (n=167) worked at most 16 hours per week, 3 %  Working in Pharmacy: The total factor mean was 3.81 ± 0.597 with the highest mean been reported as 3.86 for the four statements whereas the lowest mean was 3.7 ± 0.775 for the fifth statement. Similarly, a positive response rate of (86.05%) with a mean score of 3.81±0.597 was reported indicating that the factor is above medium values (Table 2).
Communication and Work Pace: The total factor mean is 3.28 ± 0.543 with the highest and lowest mean for factor statements reported to be 3.37 and 3.04 respectively. The mean for the whole factor was again observed close to 3 which indicating that the factor has a medium value for itself and statements as well (Table 3).
Patient Safety and Response to Mistakes in Pharmacy: The mean total factor reported was is 3.71 ± 0.569 with highest and lowest mean been mean 3.76 ± 0.656 and 3.63 ± 0.697 respectively indicating that the factor had medium to high values for itself and statements as well (Table 4).
Documenting Mistakes: The total factor mean was 3.35 ± 0.68 with highest and lowest mean for factor statements been 3.44 ± 0.708 and 3.36 ± 0.707 respectively again indicating that factor has a medium to high values for itself and statements as well ( Table 5).The overall comparison between the 4 parameters was made in Table No. 6.
On further evaluation, it was observed that only 1 factor i.e working in the pharmacy did not have a significant difference between means for the Years of Work groups (Table 7). However, the other two factors namely, communication and work pace as well as patient safety and responses to mistake had been found to be statistically significant with notable differences between reported with respect of groups of years working variable ( Table 7).
The areas of strength that were identified or with a high level of agreement according to Likert scale were teamwork in pharmacy, communications and work pace, response to mistakes, and documenting the mistakes. Positive responses were highest in teamwork within the pharmacy employees, (87.3% vs. 81.6%), staff training and skills within the pharmacy employees (86.35% vs. 79.25%), physical space and environment in the pharmacy (83.8% vs. 73.6%) compared to AHRQ's 2019 community pharmacy database report 21 . Lower responses were found in response to mistakes (79.75% vs. 74.4%) as compared to AHRQ's 2019 community pharmacy database report 21 .
The present findings indicated that ratings on documenting mistakes (reporting) as perceived by pharmacy employees were almost equivalent to another study conducted by AHRQ with regard to the community pharmacy in the United States 21 . Among the various factors, the weakest dimension identified was mistakes (reporting) having the lowest positive response with a mean score of 3. This denoted that a low level of agreement according to Likert scale thereby confirming that the dimension needed urgent improvements. It has been time and again reported that health care professionals play a very significant role in reducing the medication errors. The methods used in improving the process includes; the introduction of computerized physician order entry(CPOE) and the adversative drug reaction(ADR) reporting which has led to advancement in detection and prevention of the medical errors. 22 Thus, from the above findings, it can be observed that the pharmacy employees had little knowledge, attitude and practice to the existing medication errors and therefore were not aware of ways to significant reduce them. Patient safety overview in error detection and reporting require ethics, empathetic human approach, safety tools and vigilant system based on the interactive clerkships. Some of the findings from earlier studies described that pharmacy employees exhibited consciousness of the responsibility of adverse drug reaction reports and appropriate attitude towards it. 24 Health care professionals had meagre knowledge and attitude towards pharmacovigilance. It could be supplemented by the fact that among the participants not only a single ADR has been reported to the medical Centre. The study therefore guides and provides information regarding the fact that education and exercise are most acknowledged means of advancing ADR reporting as pointed out by Anderson 25 et al. Thus, proper training and appropriate curriculum development and implementation is appropriate alternative way of improving the knowledge and attitude towards ADR reporting on medical errors. This will not only result in proper identification of causes of medication errors but will also minimize sentinel events within the hospital. As per our observation in the present analysis, there are 5 stages involved in the ordering and delivery in the pharmacy department namely, monitoring, administration, dispensing, transcription and prescription. Each phase represents a susceptible link in the chain along a diversity of medical errors. The most common stage/s associated with medical error are inadequate knowledge on drug prescription and knowledge concerning the patient whom drug is prescribed for. 26 Data strongly advocates that the appropriate way of eliminating the medical error that may arise in each of the stage is by ensuring the standardization of medication process. Medication transcript error refers to communication failure between the prescribing clinician and supply staff. In the pharmacy department, it is mostly initiated by the oral medication instruction being misheard. To avoid such medical errors, it is vital to contrivance a protocol on use of verbal drug orders and take steps of including some retrospective, verification and documentation signing. Correction of medication error for the patient discharged from the pharmacy makes use of critical redundancies. The clinicians must ensure that they have confirmed the patient's status of allergy, proved weight and implemented double checking on administering high risk medicine and medication errors prone to the population as advised by Vessal. 27 Administration medical errors occur when a right drug is administered through a wrong route or a wrong drug is administered to the patient. Safety checklist helps to eliminate such type of errors and the staff is always encouraged to prescribe and offer dugs on the right dosage. 28 A possible solution to reduce medication errors is to employ full-time pharmacists, based on results of some studies like that of Plutínská and Plevová, 29 it is recommended that electronic health records together with clinical decision support systems, zero tolerance to handwritten orders, with the exception of situations requiring immediate help and a policy of not interrupting the professionals on work.
Limitations of the study: The present study was cross sectional in nature and included only the pharmacists. These limitations may include recall bias as well as communication barriers between investigators and participants. Similarly, the study was conducted only at one centre KSU University Hospital and henceforth the results cannot be generalized to the entire population.

conclusion
The current study was premeditated to evaluate the attitude, knowledge and practice of the pharmacy employees about medication errors and patient safety in King Saud University Medical City, (KSUMC), Riyadh. Among the various factors, the weakest dimension identified was mistakes (reporting) having the lowest positive response with a mean score of 3 thereby indicating that the dimension needed improvement. It is therefore suggested that future researches can be carried out using more centers and more participants to evaluate the barriers of underreporting of medication errors. Further studies could be also conducted to measure the compliance to ADR reporting with respect to different healthcare professionals and its correlation with patient safety.

acknowledgeMent
The authors are grateful to all the participants who took time to complete this survey despite a busy schedule. Special thanks to King Saud University Hospital for supporting this work under Project No. E19-4311. disclosure The authors declare no conflict of interest reFerences