Prevalence and causes of medication transcription errors among hospitalized patients: An observational study and survey of nurses at a faith-based hospital in Cameroon

Abstract


Background
The leading causes of avoidable harm in healthcare settings across the globe are unsafe medication practices and medication errors.Medication errors (MEs) are the leading cause of medication-related harm with a yearly estimated cost of US$ 42 billion globally (1).More so, resource-limited countries suffer twice as much of the burden of medication errors compared to high-income countries (1).Weak medication systems and human factors such as fatigue, inadequate environmental conditions, lack of knowledge, and work overload have been shown to affect different stages of the medication use process and could cause severe harm or death (1)(2)(3).Hospitalized patients are more vulnerable to harm from medication errors due to the severity of their illness, complex medication regimens, and fragility (1,4).
Errors can occur at any stage of the hospital's medication use process, including; prescription, transcription, dispensing, and administration.In a recent systematic review of MEs in African hospitals, errors were estimated to occur in up to 8 patients per 100 admissions.The majority of the MEs reported were prescription and administration errors and no study speci cally examined transcription errors in hospital settings (5).Many hospitals in sub-Saharan Africa still use a paper-based system and as such written doctor's prescriptions are often transcribed by nurses posing a risk for errors, however, the majority of these institutions lack a system for monitoring medication transcription errors (MTEs) (4,6).Evidence from the literature, however, indicated that transcription errors are 10 times more common for hand written orders compared to verbal or computer generated orders (7).There is, however, limited information on the burden of MTEs within hospital settings in Africa.
This study was performed to determine the prevalence and types MTEs occurring and to assess nurse's perceptions of the likely causes of MTEs within the pediatric and general wards in a Faith-based Hospital in Cameroon.

Study setting and design:
This study was carried out at Mboppi Baptist Hospital, Douala, Cameroon.Inpatients were recruited consecutively from 1st to 31st April 2021 at the general and children's ward which have a capacity of 50 and 38 beds respectively.Nursing staff working within the wards were also surveyed to explore their opinions about the causes of MTEs.During the study period, there were 20 and 37 nurses working in the children's and general wards respectively.Three general practitioners and one pediatrician were deployed in the children's ward.In the general ward, 2 general practitioners, 1 internist, and 2 general surgeons were in charge of prescribing medications to patients.This was a service improvement prospective chart review of patients admitted in the selected wards and a survey of nurses working within the wards.The hospital administration and the senior nursing supervisor were informed of the rationale for the study.The ward heads of department and nurses were blinded to prevent bias by informing them that this activity was a routine pharmacy technician ward medicine review and were MTEs that could cause harm to the patients were identi ed, the clinical pharmacist was informed and intervened to make corrections.The study was carried out in accordance with the declaration of Helsinki (8).

Medication Use Process:
Medicines are administered to patients within the wards as follows; the doctor manually writes all new prescriptions in the patient's chart, the nursing staff transcribes every new prescription onto the patient's medication administration sheet.The nurse also transcribes each medication ordered into a separate medication card which is taken to the in-patient pharmacy for collection of daily supplies using the unit dose dispensing system.Every time a medication is administered, the nurse indicates on the medication administration sheet (see Fig. 1 below).Details documented include the name, dose, dosage form/route, frequency, and duration where speci ed.

De nition Of Medication Transcription Errors
We adopted a consensus de nition for MTE from a study which used the Delphi technique among a panel of nursing healthcare professionals in Palestine.MTEs were de ned as any discrepancy between the doctor's medication order and the medication order transcribed onto the medication administration sheet and/or the medication card (4).

Data Collection:
Demographic information collected included; age, gender, and number of medications ordered.
The medical records of seventy ve patient (30 from children's ward, 45 from general ward) were reviewed daily throughout the study period.The researcher extracted details of each prescription ordered throughout admission and compared them to the nurses' transcription into the medication administration sheet and the medication cards.A transcription error was judged to have occurred if there were any modi cations or omissions of the prescription orders for the two transcription steps.MTEs identi ed where categorized according to the where they occurred (medication administration sheet, medication card, medication administration sheet and medication card).The MTEs where further categorized into the following types; wrong dose, dosage form missing, frequency missing, omission of stop medication order, omission of new medication order, wrong frequency, wrong name.Medications involved in a transcription error were categorized using the World Health Organization Anatomic Therapeutic Chemical (WHO ATC) classi cation methodology A questionnaire was designed to assess nurse's perceptions of the cause of MTEs.The questionnaire was made up of two sections.The rst section captured demographic information such as; age, gender, work experience, marital status, and ward were the nurse worked.The second section was made up of 7 questions which captured information on participant's opinion about the causes of transcription errors.
Nurses were asked to express their perceptions in section 2 using a 4 point Likert scale (1: Strongly disagree, 2: disagree, 4: agree, 5: Strongly agree).The questionnaire was pretested among 5 nurses from the maternity ensure relevance and appropriateness.
All data was collected by a third year pharmacy technician student and veri ed on a daily bases for completeness and accuracy by the project supervisor (a clinical pharmacist).

Data Analysis:
Data was entered into Microsoft excel spreadsheet, cleaned and transferred to Statistics for the Social Sciences version 23.0 (SPSS Inc., Chicago IL, USA).Continuous variables were summarized as mean (standard deviation) or median (range) and categorical variables as frequencies (percentage).
Demographic information of participants in each ward was summarized.Also the prevalence of MTEs in each ward and the proportion of MTEs by location where they occurred (administration sheet, medication card, and both) were determined.The proportion of each type of MTE in the total sample was summarized.

Demographic characteristics of study patients:
There were a total of 578 medication orders for 75 patients admitted in the children's and general wards during the study period, 53.3% (n = 40) of participants were female (Table 1).Thirty patients were admitted in the children's ward, with females making 50% (15), a mean age of 1.39 ± 2.39 years and had a median of 5 medication orders (range 1-16) during admission.In the general ward 55.6% were female (25/45), with a mean age of 52.3 ± 16.33 years, and had a median of 6 medication orders (range 1-25) throughout admission.Overall, 20 (26.7%) patients had at least one MTE.Seven (23.3%) of patients admitted to the children's ward had at least one error, whiles 13 (28.9%)from the general ward experienced at least one MTE (Fig. 2).A total of 38 MTEs were recorded with majority (n = 18, 47.4%) occurred in the medication administration sheet and the medication card, followed by MTEs that occurred only on the medication administration sheet (n = 11, 28.9%), and 23.7% (n = 9) in the medication card (Fig. 3).
The medications involved in transcription errors and the rates according to WHO ATC classi cation are described in Table 3. Antibacterials for systemic use had the most MTEs (55.3%, n = 21), followed by drugs used for diabetes and analgesics, where MTEs occurred 3 time for each.

Discussion
In this study, medication transcription errors where common among hospitalized patients, occurring in 1 out of every 4 patients.In a two-step transcription process, almost half of all errors occurred on both the medication administration sheet and the medication card.With regards to the type of errors, most were omissions of a stop or a new medication order.Antibacterial for systemic use were involved in more than half of all MTEs that occurred.The nurses in the wards identi ed illegible prescriptions, distractions, higher work load and negligence as the most likely causes of transcription errors.
The rate of MTEs observed in our study was higher than observed in an earlier report of hospitalized patients, where 5 MTEs were observed for every 100 admission (9).However, in another study conducted within an intensive care unit in Morocco, more than 400 MTEs occurred per 100 admissions (10).The observed differences might be accounted for by differences in the medication use process, targeted population, severity of illness, lack of uniformity in de nitions for MTEs, and method of reporting of errors.From the literature, studies which focused on the reporting of prescription and administration errors showed low MTE rates (5,11).The transcription step the medication use process in our setting is two stage process and majority of the MTEs occurred in both stages.There is evidence that multiple steps in the medicine use process increase the likelihood of an error occurring and approaches that standardize and simplify the medication use process improve medication safety (12,13).
The frequency of different error types reported depends on factors such as the study methodology, the medication use process within a particular setting, and the classi cation used for different error types.In this study, omission of start and stop orders were the most frequent MTEs observed which is in coherence with a previous report in an oncology unit that used a similar two step transcription process (14).Our ndings, however, are not in agreement with other studies that reported incorrect patient, route of administration, frequency, and incorrect medication added (3,10,15).According to data from some studies wrong dose errors were consistently high in different settings and corroborate with ndings from our setting were over 18% of MTEs were wrong doses (5).Most of the studies that categorized errors by type focused on prescription and administration errors and the differences in approach and methodology might have accounted for the discrepancies observed.
Findings from our study indicated that antibiotics for systemic use were the medicine class most frequently involved in MTEs which is in agreement with ndings from several studies in other resource limited settings (5,7,9,10,15).In a prospective observational study within an intensive care unit in Morocco by Naoual and colleagues, anti-infective medications were involved in the highest proportion of errors (33%) which was lower than what was observed in our study (10).Another study among hospitalized children reported a higher rate (71%) of antimicrobials implicated in medication errors compared to our ndings (9).Despite the differences in rates across studies, anti-infective medications were consistently involved in the highest number of medication errors across most studies in resource limited settings (5,7,9,10,15).This might be partially explained by the high prevalence of communicable diseases in these settings and increased consumption of antimicrobials among hospitalized patients leading to a higher chance of being involved in errors.
In a recent systematic review of medication errors and adverse events in hospitals across nine African countries, lack of knowledge, training, distractions, and high workload were frequently cited as factors which contribute to medication errors which is parallel with our ndings (5).Nurse's opinions of the likely causes of errors in our study are comparable to evidence from the literature, with the highest cause of MTEs attributed to illegible prescriptions as observed in earlier reports (15)(16)(17).Several strategies could be implemented to reduce the incidence of errors including; clear writing of orders that are non-confusing by prescribers, direct communication between all healthcare professionals involved in the medication use process, clari cations with prescribers for illegible prescriptions, adoption of computerized provider order entry systems, eliminating extended physician and nurses work schedule, and implementing medication reconciliation tools (10,12,13,16,(18)(19)(20).
This study had some strengths in that it was a prospective observational study and the ward staff were blinded to avoid the Hawthorne effect.Also it was comprehensive as medication orders transcribed for all patients were analyzed from admission to discharge during the study period.
Despite the strengths of this study, there are a number of limitations.It was a single site study carried out within a small sample in two wards over a short period of time, hence the ndings cannot be generalized to other hospitals in Cameroon.Also, examined a single step in the medication use process (transcription) and therefore does not present a comprehensive picture of medication safety practices in our setting.The incidence of MTEs could have reduced as the study progressed because the clinical pharmacist intervened where transcription errors were identi ed and nurses within the wards might have become more cautious.Also we did not assess the potential severity of MTEs identi ed and this could give a better picture of the scale of the problem in future studies.

Conclusion
There is little information on the prevalence of transcription errors within hospitals in Africa and this study adds to the literature on MTEs and the likely causes among hospitalized patients (5).MTEs were common among patients and the rates were similar in pediatric and adult patients.In the two step transcription process, majority of the errors occurred in both steps and anti-infective medications for systemic use were most frequently involved in MTEs.Illegible prescriptions, increased workload, and distractions were identi ed as the most likely causes of transcription errors.Strategies such as the elimination of the transcription step in the medicine use process could reduce workload on nurses and improve accuracy (19, 21, 22).In the future the hospital could further improve medication safety by acquiring a computerized provider order entry system which will eliminate transcription of orders and illegible prescriptions leading to reduced work load on nurses and overall improvement of patient safety.