Prevalence and causes of wrong time medication administration errors: experience at a tertiary care hospital in Pakistan.

Purpose: Wrong-time medication administration error (WTMAE) is a high risk to patient safety. It can result in severe harm, death or fatal consequences. Through this study we investigated the prevalence of WTMAEs via electronic medical administration record (eMAR) and explore the contributing factors associated with WTMAEs. Study design: A descriptive study design with quantitative research approach. Setting: Data was gathered from a private tertiary care university hospital in Karachi, Pakistan. Outcome: Determine the prevalence and causes for WTMAEs. Findings: 250,213 doses were observed, out of which 231,380 (92.5%) doses were administered and 18,833 (7.5%) doses were identified as missed doses. Administered doses (n= 231,380) were further analyzed for on-time administration (n=191,994; 83%) and wrong-time administration (n=39,386; 17%). Study showed high percentage of WTMAE’s during the night shift. Upon further exploration of WTMAEs multiple reasons for late and early medication administration were identified. Implications: Medication administration is a complex process, and WTMAE is a major area to focus for improving the accuracy of medication administration recording. The study highlights the frequency of WTMAEs and provides opportunities for improvement in nursing practices by elaborating multiple reasons for WTMAEs. Value: Technology used innovatively in the form of eMAR can significantly help in identifying medication administration errors (MAE). The study also highlights major issues of MAE requiring intervention