Journal of Pharmaceutical Care 2015. 3(3-4):54-60.

Role of Clinical Pharmacists in Early Detection, Reporting and Prevention of Medication Errors in a Medical Ward
Solmaz Hassani, Azadeh Eshraghi, Farzaneh Hematian, Morteza Taheri, Zahra Sahraei


Background: Drug utilization evaluation (DUE) is an effective process in order to identifying variability in drug use and subsequent application of effective interventions for improving  patient outcomes. In this study, appropriate uses of drugs were evaluated by pharmacy service.

Methods: A prospective, interventional study was designed for determining frequency and type of clinical pharmacists’ interventions and medication errors occurred in the infectious disease ward of Loghman hospital, affiliated to Shahid Beheshti University of Medical Sciences, Tehran, Iran during 8 months.


Results: During the 8 months of the study period, 498 errors were detected among 419 patients that admitted to infectious disease ward of Loghman hospital. Most common errors were related to DVT prophylaxis, SUP and vancomycin monitoring.


Discussion: Our result showed that clinical pharmacy interventions can have an important role in reducing adverse drug events and their activities can be effective for reducing of medication error.


clinical pharmacists, role, prevention, medical error

Full Text:




SHAPA committee of speciality practice in clinical pharmacy: SHAPA standards of practice for clinical pharmacy. J Pharm Pract Res. 2005;35:122-46.

Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274(1):29-34.

Kaboli PJ, Hoth AB, McClimon BJ, et al. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006;166(9):955-64.

Fahimi F, Moradi M, Safarnavadeh T, et al. Management of Community Acquired Pneumonia in a Teaching Hospital: The Role of Established Guidelines. Tanaffos 2007;6(2):32-7

Tavallaee M, Fahimi F, Kiani S. Drug-use patterns in an intensive care unit of a hospital in Iran: an observational prospective study. Int J Pharm Pract 2010;18(6):370-6.

Talasaz AH, Jahangard-Rafsanjani Z, Ziaie S, et al. Evaluation of the pattern of human albumin utilization at a university affiliated hospital. Arch Iran Med 2012;15(2):85-7.

Fahimi F, Baniasadi S, Behzadnia N, et al. Enoxaparin utilization evaluation: an observational prospective study in medical inpatients. Iranian J of Pharm Res 2010;7(1):77-82.

Fahimi F. Implementation of a clinical pharmacy education program in a teaching hospital: Resident oriented documentation and intervention. Iranian journal of pharmaceutical research . IJPR 2010;9(3):297.

Walton SM. The pharmacist shortage and medication errors: issues and evidence. J Med Syst 2004;28(1):63-9.

van den Bemt PM, Fijn R, van der Voort PH, et al. Frequency and determinants of drug administration errors in the intensive care unit. Frequency and determinants of drug administration errors in the intensive care unit. Crit Care Med 2002;30(4):846-50.

Berman A. Reducing medication errors through naming, labeling, and packaging. Journal of medical systems. 2004;28(1):9-29.

Phillips DP, Bredder CC. Morbidity and mortality from medical errors: an increasingly serious public health problem. Annu Rev Public Health 2002;23(1):135-50.

Fahimi F, Abbasi NM, Abrishami R, et al. Transcription errors observed in a teaching hospital. Arch Iran Med 2009;12(2):173-5.

Fahimi F, Baniasadi S, Najafi ZK. Dose switch to another dosage form of Neoral increase the risk of medication error? Ann Transplant 2008;14(4):58-60.

Fahimi F, Sistanizad M, Abrishami R, et al. An observational study of errors related to the preparation and administration of medications given by infusion devices in a teaching hospital. IJPR 2010;6(4):295-9.

Dial S, Delaney J, Barkun AN, et al. Use of gastric acid–suppressive agents and the risk of community-acquired Clostridium difficile–associated disease. JAMA 2005;294(23):2989-95.

Dial S, Delaney JC, Schneider V, et al. Proton pump inhibitor use and risk of community-acquired Clostridium difficile-associated disease defined by prescription for oral vancomycin therapy. CMAJ 2006;175(7):745-8.

Pham CQ, Regal RE, Bostwick TR, et al. Acid suppressive therapy use on an inpatient internal medicine service. Ann Pharmacother 2006;40(7-8):1261-6.

Herzig SJ, Howell MD, Ngo LH, et al. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA 2009;301(20):2120-8.

Heidelbaugh JJ, Inadomi JM. Magnitude and economic impact of inappropriate use of stress ulcer prophylaxis in non-ICU hospitalized patients. Am J Gastroenterol 2006;101(10):2200-5.

Quinlan D, Eikelboom J, Dahl O, et al. Association between asymptomatic deep vein thrombosis detected by venography and symptomatic venous thromboembolism in patients undergoing elective hip or knee surgery. J Thromb Haemost 2007;5(7):1438-43.

Pannucci CJ, Bailey SH, Dreszer G, et al. Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients. J Am Coll Surg 2011;212(1):105-12.

Erstad B, Grant K, Boucher B, et al. ASHP therapeutic guidelines on stress ulcer prophylaxis. AHSP 1999;56(4):347-79.

Koda-Kimble MA, Alldredge BK, Corelli RL, Ernst ME. Koda-Kimble and Young's Applied Therapeutics: The Clinical Use of Drugs: Lippincott Williams & Wilkins; 2012.

SK p, SK H. enteral alimentation and gastrointestinal bleeding in mechanically ventilated patients. Crit care Med 1983;11(13).

Raff T, Germann G, Hartmann B. The value of early enteral nutrition in the prophylaxis of stress ulceration in the severely burned patients. Burne 1997;23:313.

MJ S, S S. Update on stress ulcer prophylaxis in critically ill patients. Criti care Nurse 2006;26:18.

D C, D H, L G. Risk factors for clinically important upper gastro intestinal bleeding in patienta requiring mechanical ventilation. Critic Care Med 1999;27:2812.

Ross L, Wallace J, Paton J. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child 2000;83(6):492-7.

Barriere SL, Stryjewski ME, Corey GR, Genter FC, Rubinstein E. Effect of vancomycin serum trough levels on outcomes in patients with nosocomial pneumonia due to Staphylococcus aureus: a retrospective, post hoc, subgroup analysis of the Phase 3 ATTAIN studies. BMC infectious diseases 2014;14(1):183.

Bosso JA, Nappi J, Rudisill C, et al. Relationship between vancomycin trough concentrations and nephrotoxicity: a prospective multicenter trial. Antimicrob Agents Chemothe 2011;55(12):5475-9.

Hamishehkar H, Ebrahimi D, Mahmoodpoor A, et al. Drug Utilization Evaluation of Vancomycin in a Teaching Hospital in Tabriz-Iran. Pharm Sci 2015;21(1):25-29

Fahimi F, Soleymani F, Tavakoli-Ardakani M. Vancomycin Utilization Evaluation in a teaching hospital: A case- series study in Iran. J Pharm Care 2013;1:13-16

Brinkman I, Verstappen G, Veeger N, et al. Evaluation of a vancomycin dosing protocol for intensive care unit patients. Neth J Med 2015 ;73:195-8.

Khalili H, Dashti-Khavidaki S, Talasaz AH-H, et al. Anticoagulant Utilization Evaluation in a Teaching Hospital A Prospective Study. J Pharm Pract 2010;23(6):579-84.

Bauer JB, Chun DS, Karpinski TA. Pharmacist-led program to improve venous thromboembolism prophylaxis in a community hospital. AJHSP 2008;65:1643-1647

Dobesh PP, Trujillo TC, Finks SW.Role of the pharmacist in achieving performance measures to improve the prevention and treatment of venous thromboembolism. Pharmacotherapy 2013;33(6):650-64.

Khalili H, Dashti-Khavidaki S, Hossein TA, et al. Descriptive analysis of a clinical pharmacy intervention to improve the appropriate use of stress ulcer prophylaxis in a hospital infectious disease ward. JMCP 2010;16(2):114-21.

Brett S. Science review: The use of proton pump inhibitors for gastric acid suppression in critical illness. Crit Care 2005;9(1):45-50.

Haroutiunian S, Ratz Y, Rabinovich B, et al. Valproic Acid Plasma Concentration Decreases in a Dose‐Independent Manner Following Administration of Meropenem: A Retrospective Study. J Clin Pharmacol 2009;49(11):1363-9.

Schumock GT, Butler MG, Meek PD, et al. Evidence of the economic benefit of clinical pharmacy services: 1996–2000. Pharmacotherapy 2003;23(1):113-32.


  • There are currently no refbacks.

Creative Commons Attribution-NonCommercial 3.0

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.