INTRODUCTION

Medication errors pose a persistent threat to patient safety and contribute to inefficiencies across healthcare systems. The European Medicines Agency characterizes a medication error as an unintentional mistake in the drug treatment process that either causes harm or has the potential to do so.[1] These errors can occur at any stage of the medication cycle, including prescribing, transcribing, dispensing, administering, and monitoring. The errors are frequently driven by human or systemic shortcomings. While not all such errors lead to adverse drug reactions (ADRs), they are largely preventable. ADRs, in contrast, are linked to the inherent pharmacological properties of a drug and may arise even when medications are used correctly. In practice, distinguishing between preventable medication errors and unavoidable ADRs is challenging, particularly in fast-paced clinical environments.[1,2]

The global burden of medication errors is considerable, affecting both patient outcomes and healthcare resource utilization. The World Health Organization emphasized the importance of medication safety through its “Global Patient Safety Action Plan 2021–2030,” which seeks to reduce preventable harm in healthcare. Unsafe care in low- and middle-income countries is estimated to cause 134 million adverse events annually, resulting in about 2.6 million deaths.[2]

In the United Kingdom (UK), the National Health Service reported legal expenses of approximately 1.63 billion British pound related to safety lapses during the 2017–2018 period. Globally, the cost of medication errors is estimated to reach 42 billion United States dollars annually, excluding indirect losses such as diminished productivity or increased treatment costs.[3-5] A UK-based study further categorized the prevalence of medication errors across care settings and types, identifying prescribing errors (21.3%), administration errors (54.4%), and dispensing errors (15.9%) as the most common. These occurred across primary care (38.3%), care homes (41.7%), and secondary care (20%).[6]

India faces similar concerns. Research conducted in South India reported a medication error prevalence of 14.6%, with prescribing mistakes being the most frequent.[7] At the national level, about 5.2 million medical errors are estimated annually, often linked to irrational prescribing practices.[8] Other risk factors include illegible handwriting, workplace distractions, lack of clinical experience, limited pharmacological knowledge, time pressure, look-alike/ sound-alike drugs, polypharmacy, communication breakdowns, and a reluctance to report errors due to fear of blame or legal consequences. In addition, burdens such as overcrowding, inadequate infrastructure, and low health literacy further compound the risks in many resource-limited settings.[9,10] Recent institutional studies in India[11] and Nepal[12] have shown that awareness exists but practical recognition and reporting remain inconsistent. Despite these findings, limited research has focused on systematically evaluating basic medication error handling practices across multiple professional groups in tertiary care hospitals. Most existing studies emphasize incidence rates or specific subgroups, leaving a gap in understanding how day-to-day practices and reporting barriers are perceived across physicians, nurses, pharmacists, and interns.

This survey, therefore, aimed to evaluate the fundamental practices followed by healthcare professionals (HCPs) in handling medication errors at Parul Sevashram Hospital (PSH). PSH is a 750-bed NABH (National Accreditation Board for Hospitals and Healthcare Providers) – accredited tertiary care institution in the Waghodia region of Vadodara, Gujarat, India. The study also tested the feasibility of using a concise, de novo survey scale administered through Google Forms to capture responses from a large, diverse hospital workforce.

MATERIAL AND METHODS Ethical approval

The study received approval from the Institutional Ethics Committee of Parul University (Ref: PUIECHR/ PIMSR/00/081734/4915) and was conducted in accordance with the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants before data collection.

Study design and participants

This was a cross-sectional survey. Data were collected over 2 months (September-November 2024). The target population included physicians, nurses, pharmacists, and interns working at PSH.

Development of the questionnaire and validation

A structured 13-item questionnaire was developed de novo in English following a comprehensive literature review[13,14] and expert consultations. It comprised three demographic items, nine practice-related items on medication error handling, and one related to barriers. To facilitate straightforward analysis, all practice-related items were binary-coded (Yes = 1, No = 0). A pilot feasibility test was conducted with 15 HCPs to confirm clarity, comprehension, and completion time. Feedback indicated that the survey was concise and easy to complete, supporting its feasibility for large-scale distribution. Content validity was ensured through expert review. Internal consistency was evaluated in the main study sample using Cronbach’s alpha, with a value of 0.70 or higher indicating acceptable reliability. The full questionnaire is presented in Table 1.

Table 1: Questionnaire with alternative objective answers.

Question Alternative objective answers Questions collecting basic demographics of HCPs What is your profession? •Physician
•Pharmacist
•Nurse
•Medical/pharmacy/nursing intern What is your gender? •Male
•Female What is your age group? •18–30 years
•31–50 years
•51–65 years
•>65 years Question (Q) evaluating medication error handling practice Q1. Do you know what medication error is? •Yes
•No Q2. Do you know medication error can occur in prescribing, dispensing, administering, packaging, storing, or labeling? •Yes
•No Q3. Do you know medication error can lead to adverse drug reaction? •Yes
•No Q4. Have you experienced or become aware of any medication error occurrence? •Yes
•No Q5. Have you considered reporting a medication error after becoming aware? •Yes
•No Q6. Have you taken suitablemeasures to rectify the medication error? •Yes
•No Q7. Do you explain and encourage patient to report medication error? •Yes
•No Q8. Do you think it is important to prevent medication error to improve patient safety? •Yes
•No Q9. Do you think periodic training on medication error will help to build culture of reporting at institute? •Yes
•No Q10. What do you think is the most significant barrier in reporting medication errors? • Unable to recognizean error
• Lack of knowledgefor error reporting
• Unaware of thereporting system
•Heavy workload
•Fear of reporting Inclusion and exclusion criteria Inclusion criteria

Physicians, pharmacists, nurses, and interns employed at PSH during the study period

Provided informed consent

Able to read and understand English.

Exclusion criteria

HCPs not directly involved in patient care (e.g., administrative or support staff)

Declined to provide informed consent

Lacked English proficiency.

Sampling and data collection

The required sample size was estimated using the Raosoft online calculator (http://www.raosoft.com/samplesize.html), based on a 95% confidence level, 5% margin of error, and a population size of 20,000. The minimum calculated sample size was 377. To ensure sufficient participation, the questionnaire was disseminated to 600 HCPs.

The survey was administered electronically through Google Forms, and the link was disseminated through WhatsApp. This approach enabled rapid distribution among busy hospital staff but may have introduced sampling bias by favoring digitally active participants. WhatsApp was selected as the distribution channel because it is widely used among HCPs in India, allowing for practical, timely, and cost-effective communication. All items were marked as required, so incomplete responses could not be submitted. Participation was voluntary and anonymous. Although convenience sampling was employed, efforts were made to circulate the survey link across all professional categories to improve representation.

Scoring and data analysis

Each participant’s responses generated a total score ranging from 0 to 9. Scores were categorized as excellent (8–9), good (6–7), average (4–5), and poor (<4). These cut-offs were exploratory and intended for descriptive grouping in this study; they have not been externally validated. Descriptive statistics were calculated using Microsoft Excel, and inferential analyses were conducted in the Statistical Package for the Social Sciences version 31.0. The association between professional category and consideration of error reporting was examined using the Chi-square test, with effect size estimated using Cramer’s V. Statistical significance was set at P < 0.05.

RESULTS

A total of 433 out of 600 distributed surveys were completed, yielding a response rate of 72.17%. The minimum required sample size was 377, and the achieved responses exceeded this threshold. Respondents included nurses (41.3%), pharmacists (23.8%), interns (33.5%), and one physician (0.2%), indicating a marked imbalance in professional representation. Demographic details are presented in Table 2. Primary outcomes focused on awareness and handling practices of medication errors. Among respondents, 94.0% (n = 407) were familiar with the concept of medication errors, and 97.2% recognized that such errors may occur at multiple stages of medication use, including prescribing, dispensing, administration, labeling, packaging, and storage. In addition, 95.4% (n = 413) understood that medication errors could lead to ADRs.

Table 2: Demographic characteristics of respondents (n=433).

Demographics Respondents Responses (n) Percentage (%) Profession Physician 1 0.23 Pharmacist 169 39.03 Nurse 179 41.34 Medical/pharmacy/nursing intern 84 19.40 Gender Male 141 32.56 Female 294 67.90 Age group 18–30 years 402 92.84 31–50 years 28 6.47 51–65 years 3 0.69 >65 years 0 0

Direct experience or observation of medication errors was reported by 284 respondents (65.6%). Of these, 90.5% indicated that they had considered reporting the error, and 86.6% reported taking corrective actions.

With respect to patient engagement, 92.4% of participants stated that they encourage patients to report medication-related issues, while 98.2% agreed that preventing medication errors plays a critical role in improving patient safety. Moreover, 93.8% believed that regular training could help strengthen an institutional culture of error reporting. A summary of these responses is presented in Figure 1.

Figure 1: Relative distribution of responses.

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Score distribution

Based on the cumulative practice score (maximum = 9), respondents were classified into four categories:

Excellent practice (score 8–9): 59.1%

Good practice (score 6–7): 30.5%

Average practice (score 4–5): 7.9%

Poor practice (score <4): 2.5%

The overall distribution is shown in Figure 2. These thresholds were applied for descriptive purposes in this study and are not externally validated.

Figure 2: Score of respondents regarding their practice in medication error handling.

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Secondary outcomes examined perceived barriers and subgroup differences. The most frequently cited barrier was difficulty identifying errors (39.5%), followed by fear of blame (23.5%) and lack of procedural knowledge (21.2%).

A Chi-square test demonstrated a statistically significant association between profession and willingness to report errors (χ2 [3, N = 433] = 11.873, P = 0.008, Cramer’s V = 0.166, 95% confidence interval [CI]: 0.05–0.26), suggesting a small-to-moderate effect size.

Subgroup analysis indicated that nurses reported higher awareness but comparatively lower confidence in reporting than pharmacists. Interns demonstrated strong willingness to report but lower accuracy in error identification. With only one physician respondent, meaningful subgroup comparisons for this group were not possible, and this imbalance is acknowledged as a study limitation.

DISCUSSION

Medication errors remain a significant concern across healthcare environments, contributing to adverse patient outcomes and operational inefficiencies. This study assessed how HCPs in a tertiary care facility perceive and manage such errors. Findings suggest a generally high level of awareness among respondents, yet persistent challenges in error recognition and consistent reporting.

A key strength of this study is the concise 9-item de novo scale supported by an acceptable internal consistency (Cronbach’s alpha = 0.777) which reduced participant burden and likely contributed to the high response rate (72%, n = 433). Despite its brevity, the scale captured focused domains and provided meaningful insights into institutional practices. The mean score of 7.55 (standard deviation = 1.45) indicated that 59.1% of participants demonstrated excellent practices, though variations were observed across professions. The classification of participants into categories such as “excellent” or “good” was based on scoring thresholds developed for descriptive purposes in this study. These cut-offs have not been externally validated, and results should therefore be interpreted cautiously. Future research should consider using validated tools with standardized scoring systems to enable generalizable comparisons.

Although most participants expressed willingness to report or address medication errors, these findings are based on self-reported data and may not accurately reflect actual behavior in clinical settings. Such limitations are common in survey-based research, where responses can be influenced by social desirability or idealized self-perception.[15] While the results suggest readiness to support reporting and patient safety initiatives, it remains uncertain how these attitudes translate into practice. Future studies employing audit methods, direct observational approaches, or longitudinal designs would help validate these findings and capture changes in reporting behavior over time.

While most participants recognized the potential for medication errors to lead to ADRs, fewer expressed confidence in identifying such errors in real time. This finding aligns with previous studies from Palestine[14] and international reviews[16] showing that theoretical awareness does not always translate into practical competency.

A statistically significant association between professional role and willingness to report errors (χ2 [3, n = 433] = 11.873, P = 0.008, Cramer’s V = 0.166, 95% CI: 0.05–0.26) suggests profession-specific responsibilities influence reporting behavior. However, the results also revealed an imbalance in professional representation, with only one physician participating and nurses being overrepresented. This imbalance limits the reliability of interprofessional comparisons and reflects challenges seen in other surveys, where physicians are often less engaged due to clinical workload and competing priorities. Similar trends have been reported in previous studies, suggesting that scheduling conflicts and differing levels of interest in survey-based initiatives may contribute to such disparities.[17,18] Future research should focus on strategies such as departmental endorsement, in-person recruitment, or integrating surveys within clinical meetings to improve physician participation and ensure more balanced representation across professions.

In this survey, difficulty in identifying errors was the most frequently cited barrier, which contrasts with earlier studies where time constraints, fear of blame, or lack of procedural knowledge were more prominent.[13,17,19] This variation indicates the need for training focused on real-time recognition and clinical judgment rather than system-level policy alone. A systematic mixed-methods review further indicated that beliefs about consequences, emotional context, environmental support, and professional identity strongly influence medication error reporting.[20] More recently, a 2025 meta-analysis from Ethiopia highlighted limited awareness and weak institutional systems as major barriers to reporting.[21] Together, these findings indicate that while awareness alone is insufficient, successful reporting also depends on structural and cultural support.

Although not a primary objective, the use of Google Forms proved to be a practical and efficient tool for data collection. However, distributing the survey through WhatsApp may have introduced sampling bias by favoring participants who were more digitally active. Another limitation was the use of Yes/No questions. While this format simplified data collection and analysis, it restricted response detail. Nuances such as levels of confidence or attitudes might have been better captured with Likert-scale options. The binary format may also have led to an overestimation of true awareness or engagement. These limitations highlight the need for future studies using more detailed response scales and alternative study designs, such as observational or longitudinal approaches, to validate and extend these findings.

Despite its limitations, this study revealed generally positive attitudes toward medication error prevention and a willingness among HCPs to support safety initiatives. These findings are consistent with earlier studies showing nurses’ favorable perceptions of medication safety,[11,12] pharmacists’ openness to reporting near misses,[22] and broader support among HCPs for institutional reforms and training.[23] Together, these trends indicate a supportive environment for implementing future strategies that strengthen reporting systems, enhance communication, and promote ongoing education.

CONCLUSION

This cross-sectional survey represents the first institutional online assessment of HCPs’ practices related to medication error management. The 9-item practice scale demonstrated acceptable reliability (Cronbach’s alpha = 0.777), indicating potential value for internal assessments and future training evaluations. A gap between theoretical knowledge and practical application was observed in respondents. The findings were interpreted with caution due to the reliance on self-reported data, binary response options, and critical imbalance in professional representation, with only one physician respondent. These findings underscore the need for profession-specific training, validated tools, incorporation of more nuanced response formats, and interprofessional collaboration to strengthen a culture of reporting and improve patient safety. The survey’s concise de novo design and high completion rate demonstrate feasibility for use in tertiary care institutions. Future research should include more balanced interprofessional samples and consider observational or longitudinal designs to validate these findings.