Year 2021
October 2021


Abstract Title
Understanding prescription incidents in a primary care setting to improve medication safety: A Retrospective Study



NHG Polyclinics1, MOH Holdings Pte Ltd (MOHH)2, NHG Pharmacy3 

Background & Hypothesis

Prescription near-miss can potentially cause patient harm but do not, due to chance or interception. We termed those intercepted events which were rectified, as ‘prescription incidents’.  

We aimed to identify significant factors associated with prescription incidences to enable better planning of interventions to reduce incident rates.


A retrospective cross-sectional study was conducted using data from one polyclinic for March 2021. Data were collected from pharmacy audit database and patient medical records. Data were analysed descriptively and multi-linear regression with log-link function to investigate the associations between prescription incidents and patient demographics, number and type of chronic conditions, shared care or care transitions, physician employee status, and prescriptions characteristics.


There were 526 prescription incidents(incident rate=2.69%), involving 447 patients and 56 physicians. A significant proportion of incidents(n=179,34.0%) were associated with shared care or care transitions between healthcare settings including specialist clinics(n=114,63.7%), inpatient discharges(n=44,24%), private general practices(n=17,9.5%), and nursing homes(n=4,2.2%). These incidences commonly involved anti-hypertensives(n=32,18.0%), vitamins(n=28,15.7%), anti-diabetics(n=27,15.2%), and anti-lipids(n=21,11.8%). Of note, most incidents involving anti-lipids were wrong frequencies particularly OM instead of ON or vice versa. Our descriptive findings were congruent with our multilinear regression analysis: hypertension, diabetes, and having shared care or care transitions were significantly associated with prescription incidents.

Discussion & Conclusion

Every prescription incident is an averted potential medication error. The occurrence of prescription incident was higher in patients with shared care or care transitions, especially shared care with Specialist Outpatient Clinics. Multi-level interventions addressing these patients and increasing awareness on specific types of incidents across all stakeholders will likely improve medication safety.