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Saudi Pharmaceutical Journal (2013) 21, 159–164

King Saud University

Saudi Pharmaceutical Journal

www.ksu.edu.sa www.sciencedirect.com

ORIGINAL ARTICLE

Medication safety practices in hospitals: A national

survey in Saudi Arabia

Hisham Aljadhey a,*, Abdulaziz Alhusan

a , Khalid Alburikan

a , Mansour Adam

a ,

Michael D. Murray b , David W. Bates

c

a Medication Safety Research Chair and Department of Clinical Pharmacy, College of Pharmacy, King Saud University,

Saudi Arabia b Purdue University College of Pharmacy and Regenstrief Institute, Indianapolis, IN, USA

c Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA

Received 2 June 2012; accepted 31 July 2012

Available online 8 August 2012

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KEYWORDS

Medication safety;

Hospitals;

Saudi Arabia

Corresponding author. Ad

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udi Arabia. Tel.: +966 5300

-mail address: haljadhey@k

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Abstract Background: Medication errors in hospitals are a worldwide concern. The World Health

Organization has recommended the implementation of basic applications in healthcare systems to

improve medication safety, but it is largely unknown whether these recommendations are adhered

to by hospitals. We assessed the presence of core medication safety practices in Saudi Arabian hos-

pitals.

Methods: We developed and validated a survey to assess medication safety practices in hospitals.

Major headings included Look-Alike Sound-Alike (LASA) medications, control of concentrated

electrolyte solutions, transitions in care, information technology, drug information and other med-

ication safety practices. Trained pharmacists visited samples of hospitals from all regions of Saudi

Arabia.

Results: Seventy-eight hospitals were surveyed. Only 30% of the hospitals had a medication

safety committee and 9% of hospitals had a medication safety officer. Only 33% of hospitals

had a list of LASA medications and 50% had a list of error-prone abbreviations. Concentrated elec-

trolytes were available in floor stock in 60% of the hospitals. No hospital involved pharmacists in

obtaining medication histories and only 37% of the hospitals provided a medication list to the

irector of Medication Safety

ademic Affairs, College of

. Box 2475, Riyadh 11451,

(H. Aljadhey).

Saud University.

g by Elsevier

. Production and hosting by Elsevier B.V. All rights reserved.

05

160 H. Aljadhey et al.

patients at discharge. While 61% of hospitals used a computer system in their pharmacy to enter

prescriptions, only 29% of these hospitals required entry of patient’s allergies before entering a drug

order.

Conclusions: Core practices to improve medication safety were not implemented in many hospi-

tals in Saudi Arabia. In developing countries, an effort must be made at the national level to

increase the adoption of such practices.

ª 2012 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.

1. Introduction

Medication errors occurring in hospitals have become a world- wide concern for healthcare policy makers, professionals and the public. These errors harm at least 1.5 million United States

residents annually, and treating injuries caused by these errors cost at least 3.5 billion dollars (Aspden et al., 2006). In one U.S. study in two academic hospitals, the incidence of adverse

drug events (ADEs) for hospitalized patients was estimated to be 6.5 per hundred admissions (Bates et al., 1995). A more re- cent study in community hospitals found an even higher rate of ADEs of 15 per hundred admissions (Hug et al., 2010). In Aus-

tralia, up to 4% of all hospital admissions are medication- related (Runciman et al., 2003). In Saudi Arabia, two recent studies estimated that the prevalence of prescribing errors in

hospital inpatient ranges between 13 and 56 per 100 medica- tion orders (Al-Dhawailie, 2011; Al-Jeraisy and M., 2011). These data suggest that medication safety is an important

international contributor to morbidity and costs of healthcare. In the past decade, research has shown that many interven-

tions could decrease the frequency of medication errors. Many

of these interventions include the use of information technol- ogy and automation, while others use other approaches such as involving a pharmacist with the medical team or the appli- cation of core practices aimed at preventing ADEs (Aspden

et al., 2006; Bates et al., 1998; Poon et al., 2006; Cohen et al., 2005; Vira et al., 2006; Gleason et al., 2004; Cavin and Sen, 2005; Nester and Hale, 2002; Bond et al., 2000, 1999,

2002; McFadzean et al., 2003; Tam et al., 2005; Strunk et al., 2008). For example, the use of computerized physician order entry reduced the serious medication error rate by

55% (Bates et al., 1998) and the use of bar-code technology minimized the rate of dispensing errors by 31% (Poon et al., 2006). One study suggested that having a medication safety officer in the hospital may be associated with a lower rate of

ADEs (Cohen et al., 2005). Also, studies repeatedly show that ascertaining a patient’s medication history at admission by a pharmacist decreases medication errors (Vira et al., 2006;

Gleason et al., 2004; Cavin and Sen, 2005; Nester and Hale, 2002; Bond et al., 2000, 1999, 2002; McFadzean et al., 2003; Tam et al., 2005; Strunk et al., 2008).

Though research has shown the value of these interventions in reducing medication error rates, the extent to which they are implemented in hospitals around the world is poorly under-

stood. In 2005, the World Health Organization (WHO) launched the World Alliance for Patient Safety. In 2007, the Alliance recommended patient safety solutions to help prevent medication errors and adverse events. Adherence to the

recommendations of the WHO regarding medication safety practices by hospitals is unknown. No study had previously been conducted in Saudi Arabia to assess the current state of

medication safety practices in hospitals. Understanding the

current status of activities and practices would guide policy makers and healthcare professionals on areas for improve- ment. The aims of the current study were to assess the presence of core medication safety practices in Saudi Arabian hospitals

and assess the association between safety practices and hospital characteristics.

2. Methods

2.1. Design and setting

In Saudi Arabia, hospitals are either governmental or private. Governmental hospitals can be classified as either Ministry of

Health or non-Ministry of Health hospitals. Healthcare in rur- al areas is provided mainly by the Ministry of Health which runs more than 220 hospitals in all regions of Saudi Arabia.

Other governmental hospitals include National Guard hospi- tals, armed forces hospitals, security forces hospitals and spe- cialized hospitals. Private hospitals have increased in number

and size over the past few years and are mainly concentrated in major cities.

To obtain a national estimate of the frequency of imple- mentation of medication safety practices in hospitals, we strat-

ified hospitals by region and type, and then a convenient sampling technique was applied. Saudi Arabia was divided into five regions (central, north, south, east and west). We se-

lected stratified convenient samples of hospitals from each re- gion in three categories: Ministry of Health hospitals, other government hospitals, and private hospitals. Hospitals from

large cities and small towns were studied. The study was ap- proved by the Medication Safety Research Chair committee and an approval was obtained from each hospital before sur- vey completion.

2.2. Survey administration

Pharmacists interviewed the pharmacy director or inpatient

supervisor to complete the survey. Interviewers were trained by one of the study investigators on medication safety elements and each section of the survey was explained in detail. Between

March and June 2009, trained pharmacists visited conveniently selected hospitals in all regions of Saudi Arabia. Prior to visit- ing a hospital, a fax was sent which was followed by a phone

call to the pharmacy director to schedule a meeting to com- plete the survey. At the beginning of the meeting, the pharma- cists explained the purpose of the study and assured that the name of the hospital would be kept confidential. Then, phar-

macists obtained answers to the survey’s questions during a 1 h meeting.

Table 1 General characteristics of surveyed hospitals.

Factor * Number of Hospitals N (%)

Region:

Center 15 (19)

East 16 (21)

West 16 (21)

South 14 (18)

North 17 (22)

Types of hospitals:

Ministry of Health 38 (49)

Government non-Ministry of Health 14 (18)

Private 26 (33)

Number of beds:

Fewer than 100 beds 16 (21)

100–299 beds 32 (42)

300–499 beds 19 (25)

500 beds and over 9 (12)

* Total number of hospitals 78 hospitals.

Medication safety practices in hospitals: A national survey in Saudi Arabia 161

2.3. Survey development

A survey to assess the presence of core medication safety prac- tices in hospitals was developed based on the recommenda- tions of the WHO patient safety solutions, the Joint

Commission International, and the Institute for Safe Medica- tion Practices (WHO, 2011; ISMP, 2011; JCI, 2011). We selected common core practices that we believed were most important for improving the safety of medications in hospitals,

and could be feasibly implemented soon in nearly all hospitals in Saudi Arabia. The survey instrument underwent a face validity check with a number of pharmacists to ensure that

the questions were understood. The final version of the survey contained 44 questions under seven main sections.

2.4. Survey content

Hospital name and contact information were collected at the beginning of the survey. Participant hospitals were asked in

the first part of the survey if they had a medication safety com- mittee or subcommittee, a medication safety director, an error reporting system and whether the error reporting system was electronic or paper.

The second part focused on the practices to prevent medi- cation errors because of Look-Alike Sound-Alike (LASA) medications. Hospitals were asked if they have an updated list

of LASA medications, mechanisms to prevent errors from LASA medications and were asked if they provide education to healthcare professionals about these medications.

The third part consisted of three questions regarding the hospital’s policy in dealing with concentrated electrolyte solu- tions. It asked whether they keep concentrated electrolyte solu- tions in floor stock, require a second person to check the

prepared solutions and include high risk warnings on the labels of diluted electrolyte solutions.

Ten questions on practices during transitions in care were

included in the fourth section. The questions included whether the hospital ascertains a complete medication history and, if so, who conducts the history, and if the current medications

list is kept in a highly visible location. Surveyed hospitals were also asked whether they have written policies regarding listing and updating medication lists, updating the current medication

list when new orders are written, providing patients with lists of discharged medications, and educating healthcare profes- sionals about medication reconciliation when health care tran- sitions occur for patients.

The fifth section assessed the use of health information technology in patient care. Questions included whether phar- macists have electronic access to inpatient and outpatient lab-

oratory values and if a medication bar-coding system is used to verify drug orders. Interviewers also asked whether the hospi- tal has an electronic medication administration record and if

patient allergy information is required before entering a pre- scription order.

The last two sections of the survey asked about the

availability of drug information resources and the imple- mentation of other practices. These practices included the use of maximum doses for high-alert drugs, implementation of a controlled drug formulary system, the presence of a

list of error-prone abbreviations and the use of a unit dose system.

2.5. Statistical analysis

Descriptive statistics were performed to illustrate the results of the survey. Results are displayed as counts and percentages. Univariate analysis using chi-square test or fischer’s exact test

as appropriate was used to assess the association between the presence of important medication safety practices and the pres- ence of medication safety officer, medication safety committee, or hospital size. We considered a p value < 0.05 as statistically

significant. The Statistical Package for Social Science (SPSS) for windows version 14 (SPSS Inc., Chicago, IL, USA) was used for analysis.

3. Results

Seventy-eight hospitals were surveyed; 38 (49%) were Ministry

of Health hospitals, 14 (18%) were governmental non-Minis- try of Health hospitals and 26 (33%) were private hospitals (Table 1). Most of the hospitals had a capacity of 100–299

beds. Only 22 (28%) hospitals had a medication safety committee

and 7 (9%) hospitals had a medication safety officer (Table 2).

More than 50% of the hospitals did not have a list of LASA medications, a mechanism to review LASA medications and did not include brand and generic names on the labels of medications.

Concentrated electrolytes (potassium chloride, potassium phosphate, magnesium sulfate and parenteral sodium chloride solutions with concentrations greater than 0.9%) were avail-

able in floor stock in 47 (60%) hospitals. High risk warning la- bels were applied on diluted electrolyte solutions in only 34% of the hospitals. More than 40% of the hospitals did not dou-

ble-check final concentrations of prepared electrolyte solutions including calculations.

None of the hospitals involved pharmacists to ascertain patients’ medication histories and only 27 (37%) hospitals

provided patients with a list of medications at discharge. A unit dose system was implemented in 70 (90%) hospitals

and computerized drug information resources were available

in the pharmacies of 33 (43%) hospitals. Forty-five (61%)

Table 2 Medication safety practices in Saudi Arabia hospitals.

Factor * Number of Hospitals N (%)

Medication Safety Committee and error reporting systems

Medication safety committee 22 (28)

Medication safety director 7 (9)

Paper-based error reporting system used 59 (76)

Electronic error reporting system implemented 6 (12)

Look-Alike sound-Alike (LASA) medications

List (LASA) medications 26 (33)

Mechanism for reviewing LASA medications 20 (47)

Mechanism to prevent LASA medications 35 (57)

Education on LASA medications 38 (50)

Medications stored in pharmacy alphabetically 57 (73)

Diagnosis field exists in the prescription or drug order 73 (95)

Both brand and generic names included on medication labels 20 (27)

Control of concentrated electrolyte solution

Concentrated electrolytes found on floor stock 47 (60)

Second person verifies final concentrations of parenteral electrolyte solutions including calculations 39 (53)

High-risk warning label used on diluted electrolyte solution 26 (34)

Transition in care

New order required with patient admission or transfer 46 (59)

Orders ‘‘resume the same medications’’ are accepted 44 (56)

Policy to update medication list exists 52 (70)

Complete drug history taken 71 (95)

Pharmacist takes medication history 0

Current medications list put in consistent highly visible location 61 (81)

Written policies and procedures to list and update the medication list 41 (57)

Current medication list updated with new physician orders 62 (83)

List of discharge medications 27 (37)

Health care professionals educated on procedures for reconciling medications 18 (24)

Information Technology

Electronic access to inpatient laboratory values 34 (44)

Medication bar coding 9 (12)

Electronic medication administration record 21 (29)

Pharmacy uses computer to enter prescription 45 (61)

Patient allergy history is required to enter an order 13 (39)

Drug allergy verified 24 (55)

Pharmacy computer screens drug for drug allergy 13 (29)

Allergy list is clearly visible on all pages of medication administration records 53 (77)

Computer is directly interfaced with the laboratory 10 (14)

Body weight is a required field 8 (11)

Drug Information

Drug information resources in all patient care areas 47 (61)

Computerized drug information resources in the pharmacy 33 (43)

Other Medication Safety Practices

Renal or hepatic dosage adjustment for relevant patients 18 (24)

Maximum dose for high alert drug 20 (27)

Controlled drug formulary system 57 (75)

A list of error prone abbreviations is available 38 (50)

Unit dose system implemented 70 (93)

Medications brought from home by patient are not used 60 (83)

Discontinued medications are removed from patient supplies in a timely manner 62 (86)

Pharmacy staff receive baseline competency evaluation 42 (56)

* Total number of hospitals = 78.

162 H. Aljadhey et al.

hospitals use a computer system in the pharmacy to enter pre- scriptions but only 39% of these hospitals required patient

allergy information before entering a drug order. Other more advanced practices were also poorly imple-

mented, such as pharmacist electronic access to inpatient lab- oratory data, use of medication bar-coding including robotic

dispensing and electronic medications administration records. It was uncommon for a pharmacist to be involved in renal

or hepatic dosage adjustment (24%) for relevant patients. We examined the association between the presence of med-

ication safety officer, medication safety committee, or number of beds and the presence of important medication safety

Table 3 Association between important medication safety practices and hospital characteristics (presence of medication safety officer

and medication safety committee).

Variable Presence of medication safety officer P value (v2 test or Fisher’s Exact test)

Yes n (%) No n (%)

List of error prone abbreviation Yes n (%) 7 (100) 31 (44.9) 0.012

No n (%) 0 38 (55.1)

List of discharge medication Yes n (%) 4 (57.1) 23 (34.8) 0.245

No n(%) 3 (42.9) 43 (65.2)

List of LASA medications Yes n (%) 7 (100) 18 (25.7) <0.001

No n (%) 0 52 (74.3)

Presence of medication safety committee

List of error prone abbreviation Yes n (%) 18 (81.8) 20 (38.5) 0.001

No n (%) 4 (18.2) 32 (61.5)

List of discharge medication Yes n (%) 13 (59.1) 14 (28) 0.018

No n (%) 9 (40.9) 36 (72)

List of LASA medications Yes n (%) 14 (63.6) 11 (20.8) 0.001

No n (%) 8 (36.34) 42 (79.2)

Table 4 Association between important medication safety practices and hospital size.

Number of beds P value (v2 test or Fisher’s Exact test)

Fewer than 100

beds (%)

100–299

beds (%)

300–499

beds (%)

500 beds

and over

List of error prone

abbreviation

Yes n (%) 4 (25) 18 (58.1) 10 (52.6) 6

(66.7)

0.119

No n (%) 12 (75) 13 (41.9) 9 (47.4) 3

(33.3)

List of discharge

medication

Yes n (%) 4 (26.7) 10 (33.3) 6 (33.3) 7

(77.8)

0.078

No n (%) 11 (73.3) 20 (66.7) 12 (66.7) 2

(22.2)

List of LASA

medications

Yes n (%) 3 (18.8) 11 (34.4) 7 (36.8) 4

(44.4)

0.553

No n (%) 13 (81.2) 21 (65.6) 12 (63.2) 5

(55.6)

Medication safety practices in hospitals: A national survey in Saudi Arabia 163

practices (Table 3 and Table 4). We found that the presence of a medication safety officer or committee within a hospital was highly associated with the presence of a list of error prone

abbreviations and LASA list.

4. Discussion

We assessed the presence of core medication safety practices in Saudi Arabian hospitals, and found that, there was sub- stantial opportunity for improvement, even for relatively

low-cost interventions. Only 30% of the hospitals had a medication safety committee and 9% had a medication safety officer. Furthermore, only 33% of the hospitals carry a list of LASA medications and 50% had a list of error-

prone abbreviations. Concentrated electrolytes were available as floor stock in 60% of hospitals. None of the hospitals in- volved pharmacists to ascertain patients’ medication history

and only 37% of hospitals provided patients with a list of medications at discharge.

All of the above interventions can be implemented with a relatively modest increase in resources allocated, and while this remains to be demonstrated, they might well pay for them-

selves. Further improvement in medication safety might be ex- pected with the implementation of other more costly solutions such as computer order entry and bar-coding, but the basic interventions should be implemented first.

The results of this study have important implications on practice in other developing countries similar to Saudi Arabia. Action should be taken by the healthcare professionals and

hospital administrators to implement low cost practices. These practices include lists of LASA medications, lists of discharge medications and lists of prohibited abbreviations. None of the

surveyed hospitals involved pharmacists to obtain medication histories. However, previous studies show that inconsistencies in medication histories occur in up to 61% of patients admit-

ted to hospitals (Vira et al., 2006; Gleason et al., 2004; Cavin and Sen, 2005; Nester and Hale, 2002; Bond et al., 2000, 1999, 2002; McFadzean et al., 2003; Tam et al., 2005) and pharmacists could help to significantly reduce these errors by

164 H. Aljadhey et al.

obtaining the patients’ medication history at the time of hospi- tal admission (Strunk et al., 2008).

When hospitals are preparing for accreditation they will

implement many practices required for accreditation, which in turn will improve the safety of medication practices in these hospitals. However, not all countries require that hospitals ob-

tain national or international accreditation. In Saudi Arabia, accreditation was not required for hospitals until the establish- ment of the Central Board of Accreditation for Healthcare

Institutions (CBAHI) in 2006. Pharmacy standards for CBA- HI included most of the practices included in the current study. One may argue that to benefit from these practices education and culture change are also essential, which is unlikely to be

gained by accreditation alone. Future studies need to focus on changing the culture and studying the reasons for not implementing medication safety practices in hospitals.

In Saudi Arabia, a national center to address medication safety is needed to focus on research and work collaboratively with CBAHI and various health care systems. This center

could evaluate innovative interventions, including their cost- effectiveness, disseminate knowledge and assist in implement- ing applications to improve the safe use of medications.

Because resources are scarce in developing countries, it is espe- cially important to determine which interventions have the most impact, although some such as removal of concentrated electrolyte solutions from floor stock should simply be imple-

mented. Installation of state-of-the-art applications in a partic- ular hospital does not automatically result in a safer environment for patients in that hospital.

This study has several limitations. The responses of phar- macy directors to the survey were not verified. Such verifica- tion for the presence of practices would require inspection of

the pharmacy which was not welcomed by most hospitals. Another limitation was that the survey asked general questions regarding the presence of certain practices and we did not

ascertain the details about each practice. In summary, core practices to ensure medication safety

were not implemented in many hospitals in Saudi Arabia. To improve the safe use of medications in developing countries,

an effort at a national level is needed in hospitals and this effort should include standards, certification, regulation, and support for research, regulation and education.

Acknowledgements

We acknowledge the support from the Medication Safety Re- search Chair at King Saud University and support from the National Plan for Science and Technology (09-BIO708-02).

References

Al-Dhawailie, A., 2011. Inpatient prescribing errors and pharmacist

intervention at a teaching hospital in Saudi Arabia. Saudi

Pharmaceutical Journal. 19, 193–196.

Al-Jeraisy, M., Alanazi, M., Abolfotouh, M., 2011. Medication

prescribing errors in a pediatric inpatient tertiary care setting in

Saudi Arabia. BMC Res Notes. 4,294.

Aspden, P., Wolcott, J., Bootman, J.L., 2006. Committee on Identi-

fying and Preventing Medication Errors. Institute of Medicine

National Academy Press, Preventing Medication Errors, Washing-

ton, DC.

Bates, D.W., Cullen, D.J., Laird, N., Petersen, L.A., Small, S.D.,

Servi, D., Laffel, G., Sweitzer, B.J., Shea, B.F., Hallisey, R., et al.,

1995. Incidence of adverse drug events and potential adverse drug

events. Implications for prevention. JAMA 274 (1), 29–34.

Bates, D.W., Leape, L.L., Cullen, D.J., et al., 1998. Effect of

computerized physician order entry and a team intervention on

preventing serious medication errors. JAMA 280 (15), 1311–1316.

Bond, C.A., Raehl, C.L., Franke, T., 1999. Clinical Pharmacy Services

and Hospital Mortality Rates. Pharmacotherapy 19 (5), 556–564.

Bond, C.A., Raehl, C.L., Franke, T., 2000. Clinical Pharmacy

Services, Pharmacy Staffing, and the Total Cost of Care in United

States Hospitals. Pharmacotherapy 20 (6), 609–621.

Bond, C.A., Raehl, C.L., Franke, T., 2002. Clinical pharmacy services,

hospital pharmacy staffing, and medication errors in United States

hospitals. Pharmacotherapy 22 (2), 134–147.

Cavin, A., Sen, B., 2005. Improving medication history recording and

the identification of drug related problems in an A&E department.

Hospital Pharmacist. 12, 109–112.

Cohen, M.M., Kimmel, N.L., Benage, M.K., Cox, M.J., Sanders, N.,

Spence, D., Chen, J., 2005. Medication safety program reduces

adverse drug events in a community hospital. Qual. Saf. Health

Care. 14 (3), 169–174.

Gleason, K.M., Groszek, J.M., Sullivan, C., et al., 2004. Reconcili-

ation of discrepancies in medication histories and admission orders

of newly hospitalized patients. Am. J. Health Syst. Pharm. 61 (16),

1689–1695.

Hug, L.B., Witkowski, D.J., Sox, C.M., Keohane, C.A., Seger, D.L.,

Yoon, C., Matheny, M.E., Bates, D.W., 2010. Adverse drug event

rates in six community hospitals and the potential impact of

computerized physician order entry for prevention. J. Gen. Intern.

Med. 25 (1), 31–38.

Institute for Safe Medication Practices. Accessed on 02/03/2011.

<http://www.ismp.org/selfassessments/default.asp>.

Joint Commission International. Accessed on 02/03/2011. <http://

www.jointcommissioninternational.org>.

McFadzean, E., Isles, C., Moffat, J., Norrie, J., Stewart, D., 2003. Is

there a role for a prescribing pharmacist in preventing prescribing

errors in a medical admission unit? The Pharmaceutical Journal.

270, 896–899.

Nester, T.M., Hale, L.S., 2002. Effectiveness of a pharmacist acquired

medication history in promoting patient safety. Am. J. Health Syst.

Pharm. 59 (22), 2221–2225.

Poon, E.G., Cina, J.L., Churchill, W., Patel, N., Featherstone, E.,

Rothschild, J.M., Keohane, C.A., Whittemore, A.D., Bates, D.W.,

Gandhi, T.K., 2006. Medication Dispensing Errors and Potential

Adverse Drug Events before and after Implementing Bar Code

Technology in the Pharmacy. Ann. Intern. Med. 145 (6), 426–434.

Runciman, W.B., Roughead, E.E., Semple, S.J., Adams, R.J., 2003.

Adverse drug events and medication errors in Australia. Int. J.

Qual. Health Care 15 (Suppl. 1), i49–59.

Strunk, L.B., Matson, A.W., Steinke, D., 2008. Impact of a pharmacist

on medication reconciliation on patient admission to a veterans

affairs medical center. Hosp. Pharm. 43 (8), 643–649.

Tam, C.V., Knowles, S.R., Cornish, P.L., Fine, N., Marchesano, R.,

Etchells, E.E., 2005. Frequency, type and clinical importance of

medication history errors at admission to hospital: a systematic

review. JMAJ 173 (5), 510–515.

Vira, T., Colquhoun, M., Etchells, E., 2006. Reconcilable differences:

correcting medication errors at hospital admission and discharge.

Qual. Saf. Health Care. 15 (2), 122–126.

World Health Organization Website. Accessed on 02/03/2011. <http://

www.who.int/patientsafety/events/07/02_05_2007/en/index.html>.