Effectiveness of a prevention system on medication errors related to herbal medicines in a Thai Traditional and Alternative Medicine Group, Detudom Crown Prince Hospital
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Abstract
Medication errors related to herbal medicines that occur while herbal medicines are under the care of healthcare professionals, which may cause harm to patients or have inappropriate medication. Therefore, a special system is needed to prevent the differences. Objective: To develop a prevention system on medication errors related to herbal medicines and evaluate the effectiveness of the developed system. Methods: This action research consisted of three steps: problem analysis and development of a prevention system on medication errors related to herbal medicines; system implementation; and evaluation of the effectiveness of the developed system by comparing the rate of medication errors related to herbal medicines occurring during official working hours before and after implementing the developed medication errors related to herbal medicines prevention system. Data on medication errors related to herbal medicines related to medication prescribing, pre-dispensing processes, and dispensing from the hospital risk reporting program and the medication errors related to herbal medicines report record of the Thai Traditional Medicine and Alternative Medicine Group, Detudom Crown Prince Hospital. General data were analyzed, including the number of herbal prescriptions, the number of herbal medicine items, and the number of medication errors related to herbal medicines, using descriptive statistics (frequency). The difference in rate of medication errors related to herbal medicines was compared before and after using the developed system using Chi-squared test statistics, with statistical significance at p < 0.05. Results: The developed a prevention system on medication errors related to herbal medicines consisted of 13 measures. For example, creating a pop-up notification when prescribing herbal medicine, placing warning labels on herbal medicines with similar names or external characteristics, and dispensing herbal medicines by pharmacists, etc. After the implementation of the developed system, the overall medication errors related to herbal medicines rate in all processes can be reduced statistically significantly (p < 0.001) from 14.15 to 2.24 times per 1,000 prescriptions. Conclusion: The developed a prevention system on medication errors related to herbal medicines can effectively reduce medication errors related to herbal medicines at a Thai Traditional and Alternative Medicine Group.
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References
Bryan R, Aronson JK, Williams A, Jordan S. The problem of look‐alike, sound‐alike name errors: Drivers and solutions. Br J Clin Pharmacol. 2021;87(2):386–94. doi:10.1111/bcp.14285
Ciappolini P, Fernandez Nievas SE, Seijo M, Rodríguez MB, Vietto V, García-Perdomo HA, et al. Reducing medication errors for adults in hospital settings. Cochrane Database Syst Rev. 2021;11:CD009985. doi:10.1002/14651858.CD009985.pub2
European Medicines Agency. Guideline on good pharmacovigilance practices (GVP) for herbal medicinal products [Internet]. London: EMA; 2017 [cited 2025 Sep 25]. Available from: https://www.ema.europa.eu/en
Grauer A, Rosen A, Applebaum JR, Carter D, Reddy P, Dal Col A, et al. Examining medication ordering errors using AHRQ network of patient safety databases. J Am Med Inform Assoc. 2023;30(5):838–45. doi:10.1093/jamia/ocad007
Hospital Pharmacy Association (Thailand). Basic framework for the drug system. Bangkok: The Hospital Pharmacy Association (Thailand); 2020.
Hospital Pharmacy Association (Thailand). Basic framework for drug system 1 [Internet]. Bangkok: Hospital Pharmacy Association (Thailand); 2020 [cited 2025 Sep 26]. Available from: https://www.thaihp.org/wp-content/uploads/2022/06/ห…ระบบยา…pdf
Institute of Hospital Quality Improvement and Accreditation (Public Organization). Hospital and health service standards, 5th edition. Nonthaburi: Tieng Kwang Publishing; 2022.
National Coordinating Council for Medication Error Reporting and Prevention. What is a medication error? [Internet]. 2021 [cited 2021 Mar 17]. Available from: https://www.nccmerp.org/about-medication-errors
Office of Strategy and Planning, Ministry of Public Health. Annual focus policy 2023 [Internet]. Nonthaburi: Ministry of Public Health; 2023 [cited 2025 Sep 25]. Available from: https://spd.moph.go.th/2023-focus-policy
Rattanasaksakul J, Rattanasaksakul P. Medication error and its benefits in drug management system [Internet]. Bangkok: The Pharmacy Council of Thailand; 2017 [cited 2025 Sep 26]. Available from: https://ccpe.pharmacycouncil.org/showfile
Rattanasongkram S, Laophaibul M. Computerized prescribing system to reduce prescribing errors: A case study of Nong Han Hospital, Udon Thani Province. Isan J Pharm Sci. 2017;13:53–66.
Wang H, Tao D, Yan M. Effects of text enhancement on reduction of look-alike drug name confusion: A systematic review and meta-analysis. Qual Manag Health Care. 2021;30(4):233–43. doi:10.1097/QMH.0000000000000303
Westbrook JI, Li L, Raban MZ, Woods A, Koyama AK, Baysari MT, et al. Associations between double-checking and medication administration errors: A direct observational study of paediatric inpatients. BMJ Qual Saf. 2021;30(4):320–30. doi:10.1136/bmjqs-2020-011473
World Health Organization. Global patient safety action plan 2021–2030: Towards eliminating avoidable harm in health care [Internet]. Geneva: WHO; 2021 [cited 2025 Sep 25]. Available from: https://www.who.int/teams/integratedhealth-services/patient-safety/policy/globalpatient-safety-action-plan
