A Comparative Analysis of Electronic Prescribing Near Misses in King Saud Medical City, Riyadh, Saudi Arabia

Background: A “near miss” or close call is a medication error that happened but did not result in injury or damage to the patient. These medication errors (MEs) are captured and corrected before affecting the patient either fortuitously or purposefully by designed system controls imbedded in electronic health record (EHR) as well as electronic prescribing systems (EPS).
Objective: This study analyzed the reported electronic prescribing near misses (NMs) in King Saud Medical City (KSMC) in Riyadh city.
Methods: The ME report forms were consecutively collected over a period of one year, from 1 January to 31 December, 2012. These forms were evaluated for data abstraction and a comparative analysis of NMs/NM report forms of first 6-month (n=1025, timeline 1) versus second 6-month (n=2398, timeline 2) was carried out. No systematic intervention prior to timeline 2 was used in this study.
Results: The total number of MEs/NMs report forms was 3423 and total number of reported NMs was 7415, as each form could contain more than one NM. Drug prescription items, medication dispensing stages, NM makers and identifiers, underlying causes, sites of errors, prescribed drugs and suggested actions to avoid NM errors all differed significantly between the two timelines, which could be attributed to natural, real world practices in KSMC.
Conclusion: This prospective study found significant differences in factors related to NMs between two six month periods in a single year. Reasons for these differences between two timeframes remain poorly understood. NMs comparative studies using systematic interventions are warranted in the Kingdom of Saudi Arabia.