DEBRE MARKOS

UNIVERSITY
college of medicine
and health science department of pharmacy

Evaluation of medication prescribing error and values

of pharmacists in modification of prescribing error in
Debre Markos referral hospital,East gojam zone,North
west Ethiopia 2019/2020.
By:

1. Tariku workie ………..HSR1476/08

2. Jemila mohammed ….HSR1457/08
3. Bewketu yamrot………HSR1440/08
4. Fantaye getenet………HSR1447/08
5. Negus ambaye………..HSR1468/08
6. Meskerem birhanu…….HSR1465/08
7. Melaku mulugeta………HSR1464/08

A PROPOSAL SUBMITTED TO DEPARTMENT OF PUBLIC HEALTH,

COLLEGE OF HEALTH SCIENCE, DEBREMARKOS UNIVERSITY

OCTOBER 2019

DEBRE MARKOS,ETHIOPIA
Evaluation of medication prescribing error and values
of pharmacists in modification of prescribing error in
Debre Markos referral hospital,East gojam zone,North
west Ethiopia 2019/2020.
By:

8. Tariku workie ………..HSR1476/08

9. Jemila mohammed ….HSR1457/08
10. Bewketu yamrot………HSR1440/08
11. Fantaye getenet………HSR1447/08
12. Negus ambaye………..HSR1468/08
13. Meskerem birhanu…….HSR1465/08
14. Melaku mulugeta………HSR1464/08

A PROPOSAL SUBMITTED TO DEPARTMENT OF PUBLIC HEALTH,

COLLEGE OF HEALTH SCIENCE, DEBREMARKOS UNIVERSITY
 OCTOBER 2019

DEBRE MARKOS,ETHIOPIA

ACKNOWLEDGMENT

first of all we would like to express our heart full gratitude to almighty to god
who helped to accomplish this proposal successfully. We would like to
expanded our gratitude to department of public health and debre markos
university for giving us this educative and golden opportunity. Finallyi we
express our special feeling to simegn.A and yilikal.T for their precious and
constrictive suggestions comments and guidance from the beginning to the
completion of the research proposal.
LIST OF ABBREVIATIONS

CI- confidence interval

DMRH- debre markos referral hospital

ME- medication error

OPD- out patient department

TABLE OF CONTENT
LIST OF ABBREVIATIONS

LIST OF TABLES AND FIGURES

SUMMARY

1. INTRODUCTION

1.1 BACKGROUND

1.2 STATEMENT OF THE PROBLEM

1.3 LITERATURE REVIEW

1.4 JUSTIFICATION

1.5 SIGNIFICANCE OF THE STUDY

1.6 CONCEPTUAL FRAME WORK

2 .OBJECTIVE

2.1 GENERAL OBJECTIVE

2.2 SPECIFIC OBJECTIVE

3. MATERIALS AND METHOD

3.1 STUDY DESIGN

3.2 STUDY AREA AND PERIOD

3.3 POPULATION

3.3.1 SOURCE POPULATION

3.3 .2 STUDY POPULATION

3.4 ELIGIBILITY CRITERIA

3.4.1 INCLUSION CRITERIA

3.4.2 EXCLUSION CRITERIA

3.5 SAMPLE SIZE DETERMINATION AND PROCEDURES

3.5.1 SAMPLE SIZE DETERMINATION

3.5.2 SAMPLING TECHNIQUE AND PROCEDURE

3.6 VARIABILITY OF THE STUDY

3.6.1 DEPENDANT VARIABLE

3.6.2 INDEPENDENT VARIABLE

3.7 OPERATIONAL DEFINITION

3.8 DATA COLLECTION PROCEDURES

3.9 DATA COLLECTION TOOL

3.10 DATA QUALITY ASSURANCE

3.11 DATA ANALYSIS TECHNIQUE

3.12 ETHICAL CONSIDERATION

3.13 DISSEMINATION PLAN

4. WORK PLAN

5. BUDGET

6. REFERENCE

7 ANNEX
 LIST OF TABLES AND FIGURES

1. FIGURE 1.6.1 CONCEPTUAL FRAME WORK

2. TABLE 4.1 ACTION PLAN
3. TABLE 5.1 BUDGET DETERMINATION
SUMMARY
Background:-
1.Chapter one -INTRODUCTION
1.1.BACKGROUND
Medications are offered by health services throughout the world. However,
with substantial and increasing medication use comes a growing risk of
harm.(1) The United States National Coordinating Council for Medication
Error Reporting and Prevention defines a medication error as: any
preventable event that may cause or lead to inappropriate medication use
or patient harm while the medication is in the control of the health care
professional, patient, or consumer. Such events may be related to
professional practice, health care products, procedures, and systems,
including prescribing, order communication, product labeling, packaging,
and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring, and use.(2)

The prescription errors are mainly of two types, errors of omission and
errors of commission. Errors of omission mean prescription missing
essential information, while errors of commission mean wrongly written
information in the prescription. (3)

Prescription errors are not only monetarily costly, but costly in terms of loss
of trust in the healthcare system by patients, reduced patient satisfaction,
and degraded morale among healthcare professionals, who often feel
helpless to change the situation.(3)
the major cause of prescription error are distraction : example a nurse who
is distracted may read "diazepam" as "diltiazem." The outcome is not
insignificant-if diazepam is accidentally administered, it could sedate the
patient, or worse . Environment : A nurse who is chronically overworked can
make medication errors out of exhaustion. Additionally, lack of proper lighting,
heat/cold, and other environmental factors can cause distractions that lead to
errors. Lack of knowledge/understanding : Nurses who lack complete knowledge
about how a drug works, its various names (generic and brand), its side effects, its
contraindications, etc. can make errors. Incomplete patient information : Lacking
information about which medications a patient is allergic to, other medications
the patient is taking, previous diagnoses, or current lab results can all lead to
errors. Nurses who aren't sure should always ask the physician or cross-check
with another nurse. Memory lapses : A nurse may know that a patient is allergic,
but forget. This is often caused by distractions. Forgetting to specify a maximum
daily dose for an "as required" drug is another example of a memory-based error.
Systemic problems : Medications that aren't properly labeled, medications with
similar names placed in close proximity to one another, lack of bar code scanning
system, and other issues can lead to medical errors. (4)
Action is needed to reduce the frequency of medication errors. Pharmacists
might think that they know all about the risks that can lead to medication
errors, but the message is that knowing about risks is not the same as
taking action to prevent them. (5)

the pharmacists are responsible for for evaluating the prescription paper for
the correct dispensing of the medication .
1.2 STATEMENT OF THE PROBLEM
Medication errors have significant health and economic consequences.
Prescribing errors are known to account for a substantial proportion of all
medication errors and are an important cause of harm to patients.(6)

Undesirable outcomes of prescription error include adverse drug reactions, drug-

drug interactions, lack of efficacy, sub optimal patient adherence and poor quality
of life and patient experience. In turn, these may have significant health and
economic consequences, including the increased use of health services,
preventable medication-related hospital admissions and death. approximately 6-
7% of hospital admissions appear to be medication related, with over two-thirds
of these considered avoidable and thus, potentially due to errors.(1)

It occur on average 8.8 times per 100 prescribing medication orders, and are
70% more likely to occur at the time of hospital admission.(7) errors will increase
in this growing population of frail older people.(7)

In 1999, an expert panel of the Institute of Medicine estimated that 44,000 to

98,000 people in the United States die each year as a result of medical errors,
making medical error the sixth to ninth leading cause of death.(8)

Several, mainly observational, studies describe and, to some extent, support the
positive contribution of pharmacists in detecting and reducing the impact of drug-
related problems. On average, one in 200 prescriptions (0.49%) was found to have
been positively modified by pharmacists.(9)

different studies are conducted in different parts of the world about the
prevalence of prescription error and some extent the role of pharmacist in
preventing this prescription error. In Ethiopia the prevalence of prescription error
is studied in some area like Dessie referral hospital ,tikur anbesa specialized
hospital etc..but in debre markos referral hospital prescription error is not studied
and I would like to study the prescription errors and the pharmacists role in
evaluating the prescription paper to prevent medication error in debre markos
referral hospital.
1.3 LITERATURE REVIEW
The goal of medication therapy is the achievement of defined therapeutic
outcomes that improve a patient’s quality of life while minimizing patient risk.(10)
The pharmacist should participate in multidisciplinary committees of the
organization and take an active role in the evaluation and monitoring of the
medication-use process throughout the hospital.(10)

Research conducted in England shows Prescribing and/or monitoring errors were

detected in 4.9% (296/6048) of all prescription items (95% confidence interval [CI]
= 4.4% to 5.5%).(11)
from studies conducted at Malaysia 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).(12)

research conducted in saudiArabia from random sample of 117 prescriptions

Only 7% of drug interactions were reported between the prescribed drug.(13)

Research conducted in Nigeria a total of 2,660 (75.0%) combined prescription

errors were found to have one form of error or the other; illegitimacy 1,388
(52.18%), omission 1,221(45.90%), wrong dose 51(1.92%).(14).
Research conducted in Tikur Anbessa Specialized Hospital, Addis ababa, Ethiopia
show that the prevalence of prescription error is 40% with the Common
prescribing errors were omission errors (42.89%), wrong combination(28.13%),
wrong abbreviation(13.37%), wrong dose(8.36%), wrong frequency (5.01%) and
wrong indications (2.23%).(15)

Research conducted in Dessie referral hospital shows the overall medication

prescribing error rate was 58.07%. Incomplete prescriptions and dosing errors were
the two most common types of prescribing errors. Antibiotics (54.26%) were the
most common classes of drugs subjected to prescribing error.(16)
Research conducted in ICU of jimma University Specialized Hospital was 209/398
(52.5%).(17)

1.4 JUSTIFICATION
We conduct this research because medication prescription error is the major
cause of hospitalization ,drug adverse effect ,bacterial drug resistance ,decrease
the patients adherence ,cost etc…

Research conducted in Ethiopia about medication prescription error is limited

,their is no study about prescription error in debre markos referral hospital.

1.5 SIGNIFICANCE OF THE STUDY

Our research will show the prevalence of medication prescription error in debre
markos referral hospital . As a result it may help to prevent this error as by
providing information about the prevalence of prescription error. it may also
provide information on which types of prescription error is most likely occur and
in which drug this prescription error is occurred.
These study may also provide information on the role of pharmacist in preventing
medication prescription errors by modify the prescription paper and this may
create awareness on the profession of pharmacy.
 1.6 CONCEPTUAL FRAME WORK

Cause

 distractions

 distortion

 illegible writing

 etc…..

Prevention method
 approach every
prescription with caution
Medication prescription error
 use metric measure

 consider patient age

 liver and kidney function

test

 provide direction

 etc...

Types

 omission

 prescribing

 working time

 in proper dose

 monitoring wrong dose

preparation

 etc…
CHAPTER-TWO :OBJECTIVE
2.1GENERAL OBJECTIVE
 To asses the prevalence of medication prescription error and roles of
pharmacists on modification of prescription error in debre markos referral
hosiptal,east gojam, north west Ethiopia2019/2020.

2.2 SPECIFIC OBJECTIVE

 To determine the prevalence of medication prescription error in debre
markos referral hospital.

 To determine the role of pharmacist on modification of medication

prescription error.

 To identify the major types of prescription error

CHAPTER-THREE :MATERIALS AND METHOD
3.1 STUDY DESIGN
A cross-sectional study will be conducted to determine the prevalence of
medication prescription error and role of pharmacist on modification of
prescribing error.

3.2 STUDY AREA AND PERIOD

The study will be conducted in Debre Markos referral hospital. Which is located in
Debre Markos town, 300km away from Addis Ababa and 265km from Bahirdar,
Amhara region North West Ethiopia. According to 2007 population and house
census the Debre Markos town has 11 Keble and total populations of 2,153,937
from this population 1,066,716 are men and 1,087,221 are women with an area of
14,004.47 square kilometer .the largest ethnic group reported in east Gojjam was
the Amhara (99.82%) all other ethnic groups made up 0.12% of the population.
From this 97.42% of population are practiced Ethiopian orthodox Christianity and
2.49% were Muslim . Debre markos referral hospital is found in kebele 10. (18)
The study will be conducted at debre markos referral hospital from January 1 to
February 1 (2020).

3.3 POPULATION
3.3.1 SOURCE POPULATION
The source population will be prescription paper prescribed in DMRH.
3.3.2 STUDY POPULATION
The study population will be prescription paper prescribed in OPD.

3.4 ELIGIBILITY CRITERIA

3.4.1 INCLUSION CRITERIA
All normal prescription paper in out patient department.
3.4.2 EXCLUSION CRITERIA
Prescription paper which is referred to community pharmacy due to the absence of
medication in the OPD.
Refill prescription paper.

3.5 SAMPLE SIZE DETERMINATION AND

SAMPLING PROCEDURES
3.5.1 SAMPLE SIZE DETERMINATION
The sample size computed using the general formula for a single population
proportion.it is calculated by using the prevalence of preveious similar study of
prescribing error(P=58%),5% marigin of error and 95% confidence interval (CI)
conducted in dessie referral hospital.(16) The sample size is calculated by single
population proportion formula as follows.
n=za/22 p(1-p) /d2
n=(1.96)2 0.58(1-0.58)/(0.05)2
n=3.84*0.244 /0.0025
n=374.78
n=375
where n= the required sample size p= estimated prevalence
z=z-score at 95%CI d= margin error of 5%
their for ,375 prescription will be included in the study.
3.5.2 SAMPLING TECHNIQUE AND PROCEDURES
A convenience sampling technique will be used until the prescription paper which
is prescribed to the OPD reach the required sample size(375) and the the data will
be recorded in the check list.

3.6 VARIABLE OF THE STUDY

3.6.1 DEPENDENT VARIABLE
 prevalence of the prescribing error

3.6.2 INDEPENDENT VARIABLE

 co-morbidity
 poly-pharmacy,
 route of administration,
 age
 sex
 working time
 working experience
 eligibility of hand writing

3.7 OPERATIONAL DEFINITION

prescribing error-deviation of medication prescribing from standard practices as

indicated at standard treatment guideline.

Working time-the health professional works more than 12 hours per day.
polypharmacy-is the concurrent use of multiple medications(more than or equal
to three medication at a time.
Working experience- the health professional works for two or more than two
years on his or her job is said to be senior professional.
Omission error Implies medications ordered without specifying dose, frequency,
and route.

3.8 DATA COLLECTION PROCEDURES

the data will be collected by seven under graduate pharmacy students through
observation of the prescription paper in the OPD during the study period. The
data gain from observation will be recorded by preparing the check list. The
content of the check list include demographic variables, dates and times of
prescription, name of the medication,dosage forms, doses, frequency, and
duration of medications prescribed.
The prescription paper which is modified by the pharmacist will be also recorded
in the check list. The name the prescriber and the name of the pharmacist who
modify the prescription paper will be given identification number and recorded
in the check list.

3.9 DATA COLLECTION TOOLS

We will use structured check list and oral interview with the pharmacist. As we
will use observational data collection technique, we will use eye, paper,pen and
other sense organs as a data collection tool. The check list will be developed in
english language.

3.10 DATA QUALITY ASSURANCE

To have reliable information we will follow the correct procedure. Their for the
check list will be prepared by considering the information,s in the prescription
paper to record all the available information. And this check list will be pre-test in
DMRH in OPD unit by using 5%(19) of the total sample size.

3.11 DATA ANALYSIS TECHNIQUE

We will check the collected data for its completeness, consistency and accuracy.
Then the data will be analyzed by using SPSS software. The result will be present
by tables, graphs or figures.

3.12 ETHICAL CONSIDERATION

Before the actual data collection, the permission letter will be obtained from
department of pharmacy college of medicine and health science, debre markos
university. And submitted to debre markos referral hospital authorities. The
objective of the study will be explain to the health professionals as needed. The
privacy and confidentiality of the study participant will be maintain by giving
code for participant name.

3.13 DISSEMINATION PLAN

After compilation of the study the result will be disseminated to debre markos
university ,college of medicine and health science, department of pharmacy as a
partial fulfillment of BSC degree in pharmacy.

CHAPTER -FOUR :WORK PLAN

 Table 4.1 action plan

no activity Sept. Nov. Dec. Jan. Feb. Mar. Apr. may Jun.

1 Topic selection

2 First Proposal writing

3 Incorporating adviser
comment

4 Final proposal writing

5 Check list preparation

6 Data collection

7 Data analysis

8 First research review

9 Second research
review

10 Research defense

CHAPTER -FIVE :BUDGET

Table 5.1 budget determination

s.no item unit/price/ETB quantity Total price/ETB/item

1 paper pack/175 01 175

2 pen each/10 02 20

3 Tea and coffee - - 150

4 Internet service - - 75

5 binder - 01 5o

6 copy Page/0.5 35 17.5

7 printer page/1 35 35

8 taxi - - 120

9 Total price 642.5

CHAPTER -SIX : REFERENCE

1. Duerden M, Avery AJ, Payne RA. Polypharmacy and medicines

optimisation:making it safe and sound. London: King’s Fund; 2013
2. National Coordinating Council for Medication Error Reporting and
Prevention.What is a medication error? New York, NY: National Coordinating
Council for Medication Error Reporting and Prevention; 2015.
3. Mortazavi SA, Hajebi G. An investigation on the nature and extent of
occurrence of errors of commission in hospital prescriptions. Iranian Journal of
Pharmaceutical Research. 2010:83–7
4. https://www.medcomrn.com>index.php>articles>comm
5. The Pharmaceutical Journal, January 2004, online | URI: 20011072
6. Anthony J Avery, Maisoon Ghaleb, Nick Barber, Bryony Dean Franklin, Sarah J
Armstrong, Brian Serumaga, Soraya Dhillon, Anette Freyer, Rachel Howard, the
prevalence and definition of prescribing error. 2013 Jul 29.
doi:10.3399/bjgp13X670679
7. amanda H Lavan, Paul F Gallagher and Denis O’Mahony Methods to reduce
prescribing errors in elderly patients with multimorbidity 2016 Jun 23.
doi:10.2147/CIA.S80280
8. Stefl ME. To Err is Human: Building a Safer Health System in 1999. Front Health
Serv Manage. 2001;18(1):1–2.
9. Henk Buurma, Peter A G M De Smet, Hubert G M Leufkens, and Antoine
GEgbertsEvaluation of the clinical value of pharmacists’modifications of
prescription errors . 2004 Nov; doi: 10.1111/5.1365-2125.2004.0218.x
10. Hepler CD, Strand LM. Opportunities and responsibil-
ities in pharmaceutical care. Am J Hosp Pharm. 1990;47:533-43.
11. Avery AJ, Ghaleb M, Barber N, Dean Franklin B, Armstrong SJ, Serumaga B,
Dhillon S, Freyer A, Howard R, Talabi O, Mehta RLThe prevalence and nature of
prescribing and monitoring errors BrJGenPract.2013Aug;63(613):e543-53.doi:
10.3399/bjgp13X670679.PMID: 23972195
12. George D, Supramaniam ND, Hamid SQA, Hassali MA, Lim WY, Hss AS
Effectiveness of a pharmacist-led quality improvement program to reduce
medication errors during hospital discharge Pract (Granada). 2019 Jul-
Sep;17(3):1501. doi: 10.18549/PharmPract.2019.3.1501
13. kamel FO, Alwafi HA, Alshaghab MA, Almutawa ZM, Alshawwa LA, Hagras

MM, Park YS, Tekian AS Prevalence of prescription errors in general practice. Med
Teach. 2018 Sep;40(sup1):S22-S29. doi: 10.1080/0142159X.2018.1464648.
14. Babatunde KM, Akinbodewa AA, Akinboye AO, Adejumo AO.Prevalence and
pattern of prescription errors
Ghana Med J. 2016 Dec;50(4):233-237.
15. Sada O, Melkie A, Shibeshi W.Medication prescribing errors BMC Res Notes.
2015 Sep 16;8:448. doi: 10.1186/s13104-015-1435-y.
16. Zeleke A ,Chanie T, Woldie M.
Medication prescribing errors and associated factors at the pediatric wards Int
Arch Med. 2014 May 3;7:18. doi: 10.1186/1755-7682-7-18. eCollection 2014.
17. Asrat agalu Yemane Ayele, Worku Bedada, and Mirkuzie woldie Medication

prescribing errors in the intensive care unit of Jimma University Specialized

HospitaJ Multidiscip Healthc. 2011; 4: 377–382.
18. https://en.wikpedia.org/wiki/debre-markos

CHAPTER -SEVEN : ANNEX