Characteristics and causes of reported clozapine-related medication errors: analysis of the Ministry of Health database in Saudi Arabia

• Published in: International journal of clinical pharmacy 2024-12, Vol.46 (6), p.1410-1418
• Main Authors: AlAmri, Lamaa S., Alluwaymi, Wafa S., Alghamdi, Badr G., Alghanim, Rashed A., Almordi, Afnan S., Hettah, Reham F., Almushaikah, Sahar F., AlShahrani, Asma M., Alshammri, Nouf T., Aldossari, Salma M., AlAwn, Leena I., Alsaleh, Nada A., AlShehri, Ghadah H.
• Format: Article
• Language: English
• Subjects: Clozapine; Internal Medicine; Medical errors; Medication errors; Medicine; Medicine & Public Health; Mental disorders; Online databases; Online health care information services; Patients; Pharmacy; Primary care; Research Article; Schizophrenia
• ISSN: 2210-7703; 2210-7711; 2210-7711
• DOI: 10.1007/s11096-024-01782-2

Background Clozapine has shown great efficacy in treating treatment‐resistant schizophrenia, but it is associated with a variety of medication- related safety problems. Despite this, there remains a lack of research on medication errors (MEs) associated with its use. Aim To characterize the nature and contributory factors of clozapine-related MEs reported from government hospitals and primary care centres in Saudi Arabia (SA). Method A cross-sectional analysis was carried out on MEs related to clozapine use reported to the General Administration of Pharmaceutical Care at the Ministry of Health (MOH) in Saudi Arabia between 2018 and 2022. The data were analysed descriptively to examine the nature and contributory factors of MEs. Results A total of 1,165 MEs were reported. The majority of reported errors involved patients aged > 18 years old, with 72.2% ( n  = 841) being male. The central region was found to report errors more frequently (32.3%, n  = 376). Pharmacists were reported to detect errors most frequently (59.6%, n  = 695). MEs most often occurred in the prescribing stage (77.8%, n  = 906), with “missing prescription information” (30.1%, n  = 351) being the most frequent finding. The most frequent contributing factor was the lack of policy (33.1%, n  = 351). The majority of errors did not reach the patients (92.3%, n  = 1,075), and those that did reach patients rarely resulted in harm (0.3%, n  = 2). Conclusion This study identified areas for improvement which could expedite the development of remedial interventions to reduce the risk of errors.