REPORT MEDICATION ERROR

Medication Error Reporting System

(MERS) - Manual
MAKE OUR
HEALTHCARE
SAFER!

Pharmacy Practice and Development Division

Medication Safety Training Module
Ministry of Health Malaysia Updated July 2019
 Medication Error
Maybe
Medicationrelated
errorsto can
professional
be committed practice, (or
Any PREVENTABLE EVENT that may cause or
healthcare
contributedproducts,
to) by: procedures and systems
lead to inappropriate medication use or PATIENT
including:
• Anyone
HARM whilewho
thehandles
medication is in control of the
medicine
healthcare
Prescribing,professional, patient or consumer.
order communication, product
• Physicians/doctors, dentists, pharmacists,
labeling, packaging, compounding,
Definition

other healthcare providers, patients,

dispensing, distribution, Medication
administration,
National Coordinating Council for

caregivers etc Error Reporting and Prevention,

U.S Pharmacopeia
monitoring and use
Medication Error Reporting Syste
1) WHO can report? 2) WHAT to report?
All healthcare providers, √ All medication error (actual
both in public and error and near misses)
private sector. Χ Administrative error

WHO WHAT
6) HOW to report? 3) WHEN to report?
Anytime when

H OW
Manual/Online:
Refer to Guideline
on Medication
MERS W HEN detected an error.

Error Reporting
2019.

WHY WHERE 4) WHERE to report?

5) WHY report? a) Report using the MERS Reporting
 To learn and share experience on ME. Form and submitted to the
 To disseminate info on ME. person-in-charge.
 To formulate risk reduction strategies. b) Report to MERS Online
 To improve PATIENT SAFETY. https://mers.pharmacy.gov.my
 Responsibility

Reporter (Healthcare Professionals) Start Medication error encountered

Reporter (Healthcare Professionals) Fill in the Medication Error Reporting Form

Reporter (Healthcare Professionals) Send Medication Error report to the person- in-charge
in Medication Safety
MERS Flow Chart

Person-in-charge Medication Safety Verification

Reject
Person-in-charge Medication Safety Verify? (Rejected)
Yes

Person-in-charge Medication Safety Key-in report into MERS online

Person-in-charge Medication Safety Documentation and analyze data

End
 Let’s fill in the
Medication Error
Reporting Form
Medication Error Reporting Form
Medication Error Reporting For
Time of Process
event involved

Did the patient

Medication
Date of taken the
Error Reporting
event wrong
Form
medication/
Q1-Q9
dose?
Did error
Location of reached the
event patient?

Direct result
Location of Error on the
facility Description patient
Medication Error Reporting For
Time of
event

Date of
event

Kindly fill in the date and time when the error

occurred. Not when you report the error.
Medication Error Reporting For

Fill in the location where the error occurred.

Not the location where the error detected.
Location of
event Example:
If a prescribing error occurred in the outpatient
clinic detected in the outpatient pharmacy
Location of before dispensing, location of event should be
facility Outpatient clinic.
Medication Error Reporting For Error Description

Type of medication error, e.g. The error involved, e.g.

prescribing error/ dispensing wrong drug/ wrong
error/ administration error dose/ omitted drug Brief description of the error

Prescribing error (wrong frequency). Doctor prescribed Tab Metformin 500mg QID
instead of Tab Metformin 500mg BD. Error detected before dispensing.

Briefly describe who

detected the error

Example:
1. Dispensing error (wrong drug). PharmacistErrordispensed Tab Akurit-2 instead of Tab Akurit-4.
Description
Patient had taken T Akurit-2 for 2 weeks.

2. Administration error (wrong patient). Nurse wrongly administered 50ml of Metronidazole to

patient A who is allergy to Metronidazole instead of Patient B. Error detected by the specialist
during ward round.
Medication Error Reporting For
Process
involved

More than one options may be selected.

Medication Error Reporting For

Did the patient

An “error of omission” does reach the patient taken the
wrong
medication/
Describe the direct result on the patient (e.g. death, dose?
type of harm, additional patient monitoring). Did error
reached the
Example: No harm, harm (please specify, e.g. patient?
tachycardia/ bradycardia/ seizure attack), additional
patient monitoring includes, vital signs monitoring, Direct result
sign & symptoms of toxicity, blood glucose on the
monitoring, TDM level monitoring, Glasgow coma patient
scale, etc.
Medication Error Reporting For
Question 10:
Error
Outcome
Category
Question 19: Question 11:
Reporter’s Contributing
Details Factor

Question 18: Question

Suggestions/ 12-14:
Error
Recommendations Personnel
Details Involved

Question 17: Question 15:

Attachment Patient’s
Particulars
Question 16:
Product’s
Details
Medication Error Reporting For
Question 10:
Error
Outcome More than one options may be
Category selected.
Question 11:
Contributing
Factor

Question
12-14:  Personnel made the initial
Error error
Personnel
Details Involved  Other personnel also
involved in the error
 Personnel detected the error

Question 15:
Patient’s
Particulars
Provide the patient’s particulars
Question 16: if available:
Product’s  Age
Details  Gender
 Diagnosis
 Intended Product Error Product

• Generic Name • Generic Name

• Brand Name (optional) • Brand Name (optional)
• Dosage Form • Dosage Form
• Dose/ Frequency/ • Dose/ Frequency/
Duration/ Notes Duration/ Notes
(Example: Wrong patient/ (Example: Wrong patient/
Product Details

Omitted/ Missed drug….) Omitted/ Missed drug….)

Please fill in the additional information (Q16.5-16.7) if similar

packaging involved.
Medication Error Reporting For
Question 10:
Error
Outcome More than one options may be
Category selected.
Question 19: Question 11:
Reporter’s Contributing
Details Factor

Kindly attach Question 18: Question

12-14:  Personnel made the initial
RCA report if Suggestions/ Error
Recommendations Personnel error
available. Details  Other personnel also
Involved
involved in the error
 Personnel detected the error

Question 17: Question 15:

Attachment Patient’s
Attachment: Particulars
 Copy of prescription Provide the patient’s particulars
 Product label Question 16: if available:
Product’s  Age
Details  Gender
 Diagnosis
 What is the
common mistakes
made by the
reporter?
Common Mistakes (Reporter) Example 1:
Prescribing error (wrong frequency). Doctor in outpatient clinic prescribed Tab Metformin 500mg
QID instead of Tab Metformin 500mg BD. Error detected by the pharmacist before dispensing.

Location of event Pharmacy > Outpatient Pharmacy x Fill in the location where
the error occurred. Not

Clinic > Outpatient Clinic √ the location where the

error detected.

Example 2:
Administration error (wrong patient). Nurse wrongly administered 50ml of Metronidazole to patient
A who is allergy to Metronidazole instead of Patient B. Error detected by the in-patient pharmacist
during screening of medication chart.

Location of event Pharmacy > Inpatient Pharmacy x

Ward > Medical Ward √
Common Mistakes (Reporter) Example 3:
Prescribing error (wrong dose). Specialist in the psychiatric specialist clinic prescribed Tab
Carbamazepine 30mg bd instead of 200mg bd. Error detected before dispensing.

Contributing Factor Inexperienced Personnel

? Contributing factor: Inexperienced
personnel / inadequate knowledge
Inadequate Knowledge
? may be less appropriate for a
specialist/ consultant/ matron.

Example 4:
Omission of drug (omission of drug). Patient was not given Tab L-Thyroxine 75mcg OD and Tab
Desmopressin 0.2mg BD in the ward for 4 days. Error was detected by the specialist during ward
round. Patient required additional monitoring on thyroid function.

Error reach patient? YES Omission error consider the error

reached the patient (Cat E-I).
Wrong medication taken by the patient? YES
 Need more
information?
Medication

This guideline describes the

management of medication error and
the step-by-step process on how to fill
and submit report to the Medication
Error Reporting System (MERS).
on

Available at www.pharmacy.gov.my
Reporting
Guideline
Error
 MAKE OUR
HEALTHCARE
SAFER!

REPORT
MEDICATION ERROR
 Thank you

Medication Safety Section

Pharmacy Practice and Development Division
Pharmaceutical Services Programme
Ministry of Health Malaysia
Tel : 03-78413200
E-mail : [email protected]

Pharmacy Practice and Development Division

Medication Safety Training Module
Ministry of Health Malaysia Updated July 2019