An observational study of root-cause analysis of medication errors in elderly with methotrexate toxicity

ABSTRACT

Introduction

Medication errors are inherent in a healthcare system. This results in both time and cost burdens for both the patient and the health system. The aim of this study was to conduct a root-cause analysis of medication errors in elderly patients with methotrexate toxicity, analyze associated factors, and propose solutions.

Methods

This single-center prospective study was designed to identify medication errors in cases of methotrexate toxicity between November 2022 to May 2023. Categorical data and free-text data are used to describe incidents. Harm assessment, factors related to medication errors, and preventability were evaluated for each case. Possible strategies to prevent similar occurrences are discussed.

Results

Out of a total of 15 patients who presented during the study period, nine suffered from methotrexate toxicity due to medication errors. Most medication errors occurred during prescribing or dispensing (seven cases). Inadequate knowledge about medication and dosage, inadequate communication was identified as a contributing factor for all medication errors. Patients on long-term methotrexate treatment are at high risk of methotrexate toxicity.

Conclusion

This study highlights the challenges of health literacy and lacking communication between healthcare providers and patients that can be met through community pharmacy programs for the elderly in lower-middle-income countries.

KEYWORDS:

• Patient literacy
• methotrexate
• medication errors
• community pharmacy
• medication reconciliation

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

All authors thank all patients in the study for providing informed consent.

Data availability statement

All available original data of study was included in this article and a supplementary data sheet is also provided. All queries can be directed to corresponding author.

Author contribution statement

KB, BM, BJ were involved in the conception of article. BM, KB, BJ managed these cases after discussion with SH and MD. KB wrote the first manuscript. KB, HTS and SH revised and proofread the manuscript. BM, BJ wrote few sections of manuscript. All authors contributed to manuscript revision and the final version. Final version was approved by SH and MD.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/14740338.2024.2338257

Additional information

Funding

This paper was not funded.