A Survey of Medication Errors Reported Due to Look-Alike Antiretroviral Therapy Amongst Adult Clients at Mbagathi Hospital in Nairobi, Kenya

• Published in: Drug safety Vol. 45; no. 10; p. 1142
• Main Author: Wambura, C
• Format: Journal Article
• Language: English
• Published: Auckland Springer Nature B.V 01.10.2022
• Subjects: Abacavir; Antiretroviral agents; Antiretroviral drugs; Antiretroviral therapy; Clients; Dispensing; Drug therapy; Drugs; Emtricitabine; Health care; Health services; HIV; Human immunodeficiency virus; Lamivudine; Medical electronics; Medical errors; Morbidity; Patients; Pharmacists; Shelving; Surveys; Tenofovir; Therapy; Zidovudine
• ISSN: 0114-5916; 1179-1942

Introduction: Antiretroviral Therapy is recommended for all persons living with HIV to reduce morbidity and mortality and to prevent the transmission of the virus to others. Medications are offered by health services throughout the world, but their use comes with a substantial growing risk of harm [1]. This includes Medication Errors which is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer [2]. They are among the most common medical errors, harming at least 1.5 million people every year. The extra medical costs of treating drug-related injuries occurring in hospitals alone is at least $3.5 billion a year in addition to lost wages, loss in productivity and additional health care costs [3]. Objective: To establish the number of medication errors reported due to look-alike Antiretroviral Therapy amongst adult clients over a 12month period at Mbagathi Hospital Comprehensive Care Center Pharmacy. Methods: A survey was carried out over a 12month period between January 2021 and January 2022 to establish the number of medication errors reported due to look-alike Antiretroviral Therapy amongst Adult clients. The results of the study were captured in the medication error reporting forms at the Comprehensive Care Center Pharmacy and in a table indicating the error. Results: Over the 12month period, 2 medication errors were reported due to look-alike Antiretroviral Therapy. The medication errors reported occurred after two adult clients were dispensed with the wrong medication due to look-alike medications that were stored next to each other on the dispensing shelf. The medications were Abacavir/ Lamivudine (120/60 mg) instead of Tenofovir/Emtricitabine (300/ 200 mg) and Abacavir/Lamivudine (600/300 mg) instead of Zidovudine/Lamivudine (300/150 mg) respectively. Conclusion: Medication errors were found to have occurred over the 12month survey period. The study was able to confirm that medication errors can occur when staff lack proper training on how to store and dispense look-alike medications. It is therefore important to continuously train staff on appropriate storage and dispensing practices to avoid these medication errors and to have standard operating procedures on how to store and dispense look-alike medications. After the medication error incident we proceeded to rearranged all the look-alike medications ensuring that they were not stored in close proximity to each other and we also printed bold labels for all the medications on the shelves.