Detection of prescription errors by a unit-based clinical pharmacist in a nephrology ward

Pharm World Sci. 2010 Feb;32(1):59-65. doi: 10.1007/s11096-009-9341-9. Epub 2009 Oct 17.


Objective: To determine the impact of a clinical pharmacist on detection and prevention of prescription errors at the nephrology ward of a referral hospital.

Setting: Nephrology ward of a major referral hospital in Southern Iran.

Method: During a 4-month period, a clinical pharmacist was assigned to review medication order sheets and drug orders three times a week at the nephrology ward. Besides chart review, the clinical pharmacist participated in medical rounds once a week. The occurrence of prescribing errors, and related harm was determined on hospitalized patients in this ward during the 4 month period. When an error was detected, intervention was made after agreement of the attending physician.

Main outcome measures: Number and types of prescribing errors, level of harm, and number of interventions were determined.

Results: Seventy six patient charts were reviewed during the 4-month period. A total of 818 medications were ordered in these patients. Eighty six prescribing errors were detected in 46 hospital admissions. The mean age of the patients was 47.7 +/- 17.2. Fifty five percent were male while 45% were female. Different types of prescribing errors and their frequencies were as follows: wrong frequency (37.2%), wrong drug selection (19.8%), overdose (12.8%), failure to discontinue (10.5%), failure to order (7 %), under- dose (3.5%), wrong time (3.5%), monitoring (3.5%), wrong route (1.2%), and drug interaction (1.2 %). The attending physician agreed to 96.5% of the prescription errors detected, and interventions were made. Although 89.5% of the detected errors caused no harm, 4(4.7%) of the errors increased the need for monitoring, 2 (2.3%) increased length of stay, and 2 (2.3%) led to permanent patient harm.

Conclusion: presence of a clinical pharmacist at the nephrology ward helps in early detection of prescription errors, and therefore potential prevention of negative consequences due to drug administration.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Cross-Sectional Studies
  • Drug Prescriptions / statistics & numerical data*
  • Female
  • Hospital Units / organization & administration*
  • Hospitals, University
  • Humans
  • Iran
  • Kidney Diseases / drug therapy*
  • Male
  • Medical Staff, Hospital
  • Medication Errors* / prevention & control
  • Medication Errors* / statistics & numerical data
  • Middle Aged
  • Nephrology*
  • Pharmacists*
  • Professional Role
  • Young Adult