**5. Medication-related problems (MRP)**

#### **5.1 Introduction**

The pharmaceutical profession has evolved beyond traditional roles such as drug formulation and dispensing into a highly regulated profession focused on individualised and direct patient care [56]. Medication-related problems (MRP) are a common but preventable problem in healthcare. It is defined as 'an event or circumstance related to drug therapy that actually or potentially interferes with desired health outcomes' [57]. A medication-related problem (MRP) is a suboptimal situation in which a particular treatment regimen is likely to produce or contribute to an undesirable outcome [58].

In our daily lives, various populations simply or implicitly rely on medications to prevent and treat infections and lifelong MRPs occur in any period of drug use. They can appear after as short as an hour of medication consumption [59]. The World Health Organisation (WHO) estimates that more than half of all medicines are prescribed, dispensed or sold improperly, and more than one-half of patients do not take them correctly [60]. Previous study stipulates that pharmacists help improve drug therapy and optimise outcomes by recognising, avoiding and resolving MRPs [61]. Hospitalisations, unnecessary clinic visits and prolonged care can be caused by unresolved or latent MRPs, which not only impede clinical treatment but also increases the financial burden for patients [62]. Often, MRPs can be related to an error in drug treatment (medication error), or they can be caused by a medication side effect (adverse drug reaction) [63]. Factors such as mismanagement, population growth, poor health systems and lack of primary health care research and evaluation have limited the development of primary health care [64].

Early intervention and containment of MRPs can significantly reduce physician visits, emergency room visits, hospitalisations and healthcare costs while improving overall patient health and quality of life [65].

#### **5.2 Medication history assessment**

Upon admission to the hospital, a medication history assessment is performed to obtain and document a complete list of the patient's medication history. This includes prescription and over-the-counter medicines, dietary supplements and traditional medicines [66]. Drug histories are often incomplete, drug strengths, frequency, dosages and forms are missing, and complementary or over-the-counter (OTC) medications are often taken out. Previous studies have shown that 10–67% of drug histories contain at least one error [67]. Incorrect medication history can lead to treatment interruptions, reintroduction of discontinued medications, inappropriate treatment and undetected drug-related problems. The continuation of these errors upon discharge can lead to adverse events due to duplication of treatment, drug interactions and discontinuation of an essential medication [68]. Additional information, such as treatment adherence and past allergy or anaphylaxis and adverse reactions, should be recorded and compared to the patient's previous medical or hospital admission records [69].

A previous study in Malaysia found that 990 treatment discrepancies were identified in 390 patients recruited from three general medicine departments at Sarawak General Hospital. Of these, 135 (13.6%) medical errors were identified in 93 (23.8%) patients (1.45 errors per patient), most of which were due to medication omissions (79%) [70]. Similarly, it was found that the majority (83%) of 168 patients admitted to two gastrointestinal surgery wards and one geriatric ward at St. Olav's University Hospital in Trondheim and two general internal medicine wards at Ålesund Hospital, Norway for a period of 3 months had at least one drug discrepancy in their medical history. Drug omissions accounted for 72% of the discrepancies, while dose differences accounted for the remaining 28%. A total of 9% of the disparity could have caused serious damage or inconvenience [71].

#### **5.3 Prescribing medicines**

When there is a change in care, errors in a patient's treatment plan can occur, particularly during a hospital stay, a transfer from an emergency room to another department or intensive care unit (ICU), a transfer from an ICU or from an operating room to a ward and a transfer from the hospital to home or to another facility, such as a nursing home [68]. Previous studies found that 30%–70% were unintentional discrepancies between the medications patients were taking before admission and their prescriptions at admission [72]. In a recent study, 26.6% of these discrepancies

#### *Delivery of Pharmaceutical Care at Tertiary Level: From Admission to Home Care DOI: http://dx.doi.org/10.5772/intechopen.112503*

were due to insufficient or incorrect information on primary care medication lists, including primary care referrals and medication printouts [73].

The lack of a drug with a valid indication is the most common unintentional discrepancy, and about half of these errors can go unnoticed before impacting the patient [74]. Discrepancies during discharge often arise when prescriptions are being made and discharge notes are drawn up. An Australian study found that 15% of medications that should have been continued were omitted from the discharge prescription [75]. Another study found that 12% of patients made one or more errors in the prescriptions, including accidental omissions and discontinuation of subsequent medications [76]. Patients who forgot one or more medications on their discharge report are 2.31 times more likely than usual to be hospitalised [77].

MRPs are very common in the prescribing phase, especially in the emergency department (ED) [78]. It is estimated that at least 3% of all hospital-related adverse drug reactions occur in ED as it is among the most sought department, which offers a 24-hour medical care service [79]. A previous study conducted in the ED of a United States (US) tertiary hospital found that nearly 54% of MRPs occurred during the prescribing phase [80]. Another study conducted at a tertiary hospital in India found that MRPs are present in 16.2% of ED prescriptions [81].

A review has found that incorrect dosage, frequency and strength were the most common prescribing errors [82]. A previous systematic review of 50 published studies, mainly from Iran, Saudi Arabia, Egypt and Jordan, found that the most common factors contributing to the prescribing errors in these studies were lack of knowledge, understaffing and heavy workload [83].

Previous studies have documented the rates of prescribing errors in Australia's various acute care settings whereby insights into prescription error rates were explained when different prescribing systems (traditional and electronic) are used [84–86]. Taken together, these studies found that prescribing errors were more prominent in traditional or paper-based systems in hospitals, there were roughly about five errors per patient. Nonetheless, these mainly involve errors in the documentation such as unclear handwriting or prescriptions, missing signatures and missing routes of administration [87]. A slightly lower error rate was reported when using the standardised medical record. Some studies also found that the overall rate of typos with electronic writing systems is half of the traditional system, with about two per admission [86, 87].

#### **5.4 Medication administration**

In a previous review that looked into drug safety in critical care, it was found that medication errors varied depending on the type of system used. After excluding timing errors, they found that the rate of administration errors such as removal of therapy and incorrect dosing ranged from 5 to 8% when individualised patient delivery systems were used, and from 15to 18% when ward stock systems were in charge [88].

It was found that approximately 9% of drug administrations were associated with clinical errors (excluding timing errors) at two main teaching hospitals in New South Wales, Australia. This study also examined how the error rate changed with intrusions and disturbances during drug administration where at each occurrence, the probability of procedural and clinical errors increased by 12% and 13%, respectively [89].

Meanwhile, in an observational study involving intravenous (IV) drug administration, incorrect infusion rates accounted for 95 of the 101 major errors and bolus administration was more likely to be associated with more serious errors (23% vs. 10.6% for other IV routes). Infusion pump error rates were similar to other methods [90].
