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Abstract

Objective: To characterize medication errors across the full workflow and identify stage-specific predictors in a tertiary care setting. Medication errors remain a major global patient safety concern, with limited comprehensive analyses across all stages of the medication-use process in Saudi Arabia. Methods: A retrospective observational study was conducted using medication error reports from Al-Noor Specialist Hospital, Makkah, between January 2023 and August 2025. Errors were classified by stage and severity using the National Coordinating Council for Medication Error Reporting and Prevention index. Multivariable logistic regression was performed to identify predictors associated with each stage. Results: A total of 6,546 errors were analyzed. Most occurred during prescribing (65.5%), followed by transcribing (26.5%) and monitoring (4.4%). Incorrect or missing dose was the most common error (38.2%). Ordering-stage incidents accounted for 95.5% of reports. Pharmacists identified 86.3% of errors, and 93.5% did not reach patients (Category B). Antibiotics (32.8%) and cardiovascular medications (22.5%) were most frequently involved. Stage-specific predictors varied, with nurse detection strongly associated with administration-stage errors (odds ratio = 7.10; 95% Confidence Intervals: 2.94–16.9). Conclusion: Prescribing errors predominated, while pharmacists played a key role in error interception. Targeted, system-level interventions addressing prescribing practices and stage-specific risks are essential to improving medication safety.

Article Type

Original Study

Additional Files
Supplementary_Tables[1].docx (66 kB)
Supplementary File

First Page

1530

Last Page

1541

Creative Commons License

Creative Commons Attribution-NonCommercial 4.0 International License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License

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