Categorizing and understanding medication errors in hospital pharmacy in relation to human factors

Background: Medication errors (MEs) in hospital settings are attributed to various factors including the human factors. Human factors researches are aiming to implement the knowledge regarding human nature and their interaction with surrounding equipment and environment to design efficient and safe systems. Human Factors Frameworks (HFF) developed awareness regarding main system's components that influence healthcare system and patients' safety. An in-depth evaluation of human factors contributing to medication errors in the hospital pharmacy is crucial to prevent such errors.

Objective: This study, therefore, aims to identify and categorize the human factors of MEs in hospital pharmacy using the Human Factors Framework (HFF).

Method: A qualitative study conducted in King Saud Medical City, Riyadh, Kingdom of Saudi Arabia. Data collection was carried out in two stages; the first stage was the semi-structured interview with the pharmacist or technician involved in the medication error. Then, occupational burnout and personal fatigue scores of participants were assessed. Data analysis was done using thematic analysis.

Results: A total of 19 interviews were done with pharmacists and technicians. Themes were categorized using HFF into five categories; individual, organization and management, task, work, and team factors. Examples of these themes are poor staff competency, insufficient staff support, Lack of standardization, workload, and prescriber behaviour respectively. Scores of fatigue, work disengagement, and emotional exhaustion are correlating with medium fatigue, high work disengagement, and high emotional exhaustion, respectively.

Conclusions: The study provided a unique insight into the contributing factors to MEs in the hospital pharmacy. Emotional stress, lack of motivation, high workload, poor communication, and missed patient information on the information system, are examples of the human factors contributing to medication errors. Our study found that among those factors, organizational factors had a major contribution to medication safety and staff wellbeing.