5PSQ-032 Pre-dispensing errors involving high-alert medications among inpatients in a tertiary care hospital: a retrospective analysis

<h3>Background and Importance</h3> Medication errors during the pre-dispensing stage pose a serious risk when high-alert medications (HAMs) are involved. These errors may compromise patient safety and lead to increased healthcare costs. International guidelines emphasise the importance of system-level safeguards for HAMs.¹ <h3>Aim and Objectives</h3> This study aimed to describe the frequency, types, and monthly trends of pre-dispensing errors involving HAMs among inpatients, and to examine whether error patterns varied across pharmacy working shifts. <h3>Material and Methods</h3> A retrospective descriptive study was performed using pharmacy error records from October 2024 to July 2025. All inpatient orders containing HAMs with identified pre-dispensing errors were included. Errors were classified (wrong instructions, wrong drug/item, wrong strength, etc.). Chi-square tests were used to assess the association between detailed error types and working shifts. To address low cell counts, error types were grouped into high-frequency and low frequency categories and analysed using Fisher’s exact test. A p-value &lt; 0.05 was considered statistically significant. <h3>Results</h3> A total of 130 pre-dispensing errors were identified. The most common error categories were wrong instructions (26.9%), wrong drug/item (22.3%), wrong quantity (20.0%), and wrong strength (15.4%). The Chi-square test did not demonstrate a significant association between error type and shift (χ² = 6.46, df = 4, p = 0.167). However, when dichotomised into high- vs. low frequency categories, Fisher’s exact test showed a significant association (χ² = 6.08, df = 2, p = 0.048), with low frequency errors (eg, wrong dosage form) occurring predominantly during evening and night shifts. <h3>Conclusion and Relevance</h3> Pre-dispensing errors involving HAMs continue to be a persistent challenge. While frequent errors were evenly distributed across all shifts, rare error types appeared disproportionately during off-peak shifts, suggesting that contextual factors, such as staffing and fatigue, may have contributed to this discrepancy.² These findings support the need for both systemic safeguards and shift-specific interventions to enhance patient safety in hospital pharmacy. <h3>References and/or Acknowledgements</h3> 1. Institute for Safe Medication Practices (ISMP). ISMP list of high-alert medications in acute care settings. Horsham, PA: ISMP; 2023. 2. Phansalkar S, Hoffman JM, Murff HJ, Ash JS, Desai AA, Bell DS, Middleton B. Pharmacist workload and fatigue as potential contributors to medication errors. <i>J Patient Saf.</i> 2013;<b>9</b>(3):154–160. <h3>Conflict of Interest</h3> No conflict of interest