The Development of Inpatient Prescription Screening System to Reduce Medication Errors

Abstract

Background: Medication errors are a major cause of patient harm and mortality and can occur at any stage of the medication-use process. Prescription errors are the most frequently reported incidents and are potentially preventable through the development of effective systems.

Objective: To develop an inpatient medication order screening system within the pharmacy service workflow and evaluate its impact on the incidence, types, and severity of prescription errors.

Methods: This action research was conducted in three phases: (1) problem analysis and system development, (2) implementation of the developed system, and (3) data collection and outcome evaluation. The study was carried out in the inpatient pharmacy service from October 1, 2024, to July 31, 2025. Data were analyzed using descriptive and inferential statistics to compare outcomes before and after system implementation. The chi-square test was applied, with the significance level set at a p-value of < 0.05.

Results: After implementation of the inpatient medication order screening system, the detection rate of prescription errors significantly increased from 14.83 to 18.91 per 1,000 patient-days (p-value < 0.05). The proportion of clinically significant prescription errors (severity level C or higher) decreased from 10.93% to 8.24% (p-value < 0.05), and no errors were observed at severity levels D and E. The three most common types of prescription errors were incorrect dosage or route, inappropriate dose adjustment based on liver or renal function, and therapeutic duplication.

Conclusion: The implementation of a specialized pharmacist-led screening process with standardized criteria enhanced the detection of prescription errors, reduced their incidence and severity, and improved patient safety.