Prevalence of adverse events due to self-administration errors among patients in a tertiary care hospital: a cross-sectional study utilizing the SAME tool
DOI:
https://doi.org/10.18203/2320-6012.ijrms20253178Keywords:
Adherence, Chronic disease, Medication errors, Patient safety, Polypharmacy, Risk assessment, SAME tool, Self-administrationAbstract
Background: Self-administration medication errors (SAMEs) are a growing concern in outpatient care, especially among patients with chronic conditions requiring complex medication regimens. Despite perceived competence, many patients may be at risk of medication mismanagement, leading to adverse outcomes.
Methods: A cross-sectional study was conducted among 237 patients with chronic diseases. The SAME tool, a 10-item validated instrument (Cronbach’s α=0.814), was used to identify self-administration errors and stratify patients into risk categories. Sociodemographic and clinical data, including pill burden and comorbidities, were analyzed for associations with error prevalence.
Results: The prevalence of self-administration medication errors was 31.6%. Forgetting doses (22.4%) was the most frequent error, followed by wrong dose (11.0%) and wrong medication intake (10.1%). Multimorbidity and higher pill burden (≥6 pills/day) were significantly associated with higher error rates (p<0.05), while age and gender showed no significant correlation. Patients were classified as high risk (17.7%), moderate risk (61.2%), and low risk (21.1%) for medication errors.
Conclusions: Self-administration medication errors are common, especially among patients with multiple conditions and complex regimens. The SAME tool is effective for identifying at-risk individuals. Targeted interventions focusing on medication literacy and regimen simplification are crucial to enhance adherence and safety in outpatient care.
Metrics
References
Abdollahi GN, Sharifi N, Nazari A, Zarei E. Self-administration medication errors at home and its predictors among illiterate and low literate community dwelling older adults with polypharmacy. BMC Geriatr. 2024;24(1):346. DOI: https://doi.org/10.1186/s12877-024-05595-w
Tariq RA, Vashisht R, Sinha A, Scherbak Y. Medication dispensing errors and prevention. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.
Mira JJ, Lorenzo S, Guilabert M, Navarro I, Pérez-Jover V. A systematic review of patient medication error on self-administering medication at home. Expert Opin Drug Saf. 2015;14(6):815-38. DOI: https://doi.org/10.1517/14740338.2015.1026326
Keers RN, Williams SD, Cooke J, Ashcroft DM. Causes of medication administration errors in hospitals: a systematic review. PLoS One. 2013;8(6):68872.
Patel N, Desai M, Shah S, Patel P, Gandhi A. A study of medication errors in a tertiary care hospital. J Basic Clin Pharm. 2016;7(4):119-23. DOI: https://doi.org/10.4103/2229-3485.192039
Natarajan A, Kumar B, Rajendran P. Development and validation of self-administration medication error tool. Int J Res Med Sci. 2025;13(4):1555-62. DOI: https://doi.org/10.18203/2320-6012.ijrms20250981
Tsegaye D, Alem G, Tessema Z, Alebachew W, Ayele Y, Tilahun B, et al. Magnitude of medication administration error in self-administration. BMC Nurs. 2020;19:105. DOI: https://doi.org/10.2147/IJGM.S289452
Rasool MF, Saleem Z, Usman M, Asif N, Bukhari NI, Iqbal M, et al. Risk factors associated with medication errors among patients receiving multiple drugs. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. DOI: https://doi.org/10.3389/fpubh.2020.531038
Assiri GA, Shebl NA, Mahmoud MA, Aloudah N, Grant E, Aljadhey H, et al. What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature. BMJ Open. 2018;8(5):19101. DOI: https://doi.org/10.1136/bmjopen-2017-019101
Schneider J, Algharably EAE, Budnick A, Wenzel A, Dräger D, Kreutz R. High prevalence of multimorbidity and polypharmacy in elderly patients with chronic pain receiving home care are associated with multiple medication-related problems. Front Pharmacol. 2021;12:686990. DOI: https://doi.org/10.3389/fphar.2021.686990
Liu J, Yu Y, Yan S, Zeng Y, Su S, He T, et al. Risk factors for self-reported medication adherence in community-dwelling older patients with multimorbidity and polypharmacy: a multicenter cross-sectional study. BMC Geriatr. 2023;23(1):75. DOI: https://doi.org/10.1186/s12877-023-03768-7
Wang W, Luan W, Zhang Z, Mei Y. Association between medication literacy and medication adherence and the mediating effect of self-efficacy in older people with multimorbidity. BMC Geriatr. 2023;23(1):378. DOI: https://doi.org/10.1186/s12877-023-04072-0
Downloads
Published
How to Cite
Issue
Section
