International Journal of Clinical Pharmacy

, Volume 35, Issue 3, pp 432–438 | Cite as

The pattern of the discovery of medication errors in a tertiary hospital in Hong Kong

  • N. R. Samaranayake
  • S. T. D. Cheung
  • W. C. M. Chui
  • B. M. Y. CheungEmail author
Research Article


Background The primary goal of reducing medication errors is to eliminate those that reach the patient. Objective We aimed to study the pattern of interceptions to tackle medication errors along the medication use processes. Setting Tertiary care hospital in Hong Kong. Method The ‘Swiss Cheese Model’ was used to explain the interceptions targeting medication error reporting over 5 years (2006–2010). Main outcome measures Proportions of prescribing, dispensing and drug administration errors intercepted by pharmacists and nurses; proportions of prescribing, dispensing and drug administration errors that reached the patient. Results Our analysis included 1,268 in-patient medication errors, of which 53.4 % were related to prescribing, 29.0 % to administration and 17.6 % to dispensing. 34.1 % of all medication errors (4.9 % prescribing, 26.8 % drug administration and 2.4 % dispensing) were not intercepted. Pharmacy staff intercepted 85.4 % of the prescribing errors. Nurses detected 83.0 % of dispensing and 5.0 % of prescribing errors. However, 92.4 % of all drug administration errors reached the patient. Conclusions Having a preventive measure at each stage of the medication use process helps to prevent most errors. Most drug administration errors reach the patient as there is no defense against these. Therefore, more interventions to prevent drug administration errors are warranted.


Dispensing errors Drug administration errors Hong Kong Non-intercepted medication errors Prescribing errors Swiss Cheese Model 



The authors would like to thank Professor C.R Kumana from the Department of Medicine, The University of Hong Kong, for his guidance in writing this paper.


B.M.Y Cheung received support from the Faculty Research Fund, Li Ka Shing Faculty of Medicine, University of Hong Kong. N.R. Samaranayake holds a University Postgraduate Fellowship and a Postgraduate Scholarship from the University of Hong Kong. N.R. Samaranayake also holds the Wong Ching Yee Medical Scholarship for 2012.

Conflicts of interest



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Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • N. R. Samaranayake
    • 1
  • S. T. D. Cheung
    • 2
  • W. C. M. Chui
    • 2
  • B. M. Y. Cheung
    • 1
    • 3
    Email author
  1. 1.Department of MedicineUniversity of Hong KongPokfulamHong Kong
  2. 2.Department of PharmacyQueen Mary HospitalPokfulamHong Kong
  3. 3.Department of MedicineQueen Mary HospitalPokfulamHong Kong

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