Journal of Pharmaceutical Policy and Practice (Dec 2025)

A retrospective study on prevalence, characteristics, and outcomes of transcribing error: analysis of data from the National Medication Error Reporting System in Malaysia

  • Norazida Ab Rahman,
  • Ee Vien Low,
  • Fateha Kamaruddin,
  • Asilah Che Ayub,
  • Sue Chin Chong,
  • Noridayu Tumiran,
  • Norafidah Idris

DOI
https://doi.org/10.1080/20523211.2025.2528244
Journal volume & issue
Vol. 18, no. 1

Abstract

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Background Medication errors (MEs) represent avoidable harm that occurs within the healthcare system. While most MEs do not pose significant safety threats, some can result in severe harm, disability, or even death for patients. We aimed to describe the prevalence, characteristics, and outcomes of MEs due to transcribing errors.Methods Retrospective analysis of data from the Medication Error Reporting System (MERS) in Malaysia. All ME reports submitted to MERS were verified and classified by trained pharmacists from the Ministry of Health Malaysia. Transcribing errors were identified from all ME reports submitted to MERS that were classified as ‘data entry error’. All data from public health facilities (hospitals and clinics) submitted in 2018–2022 were included in the analysis. Descriptive analyses were conducted on frequencies and characteristics of the transcribing errors.Results From January 2018 to December 2022, 265,194 MEs were reported to the MERS, of which 12,049 (4.5%) were transcribing errors. The large proportion of transcribing error was related to dose error, i.e. incorrect dose (48.6%) and incorrect frequency (19.9%), followed by drug error (incorrect drug, 13.3% and incorrect patient, 6.3%). The majority of the errors do not reach patients (94.8%). The most possible error causes and contributing factors were work and environment followed by staff factors, task and technology, and medication-related.Conclusion There was an increase in voluntary reporting over the years, reflecting a growing culture of reporting among healthcare professionals. These findings offer valuable insights into medication errors caused by transcribing processes in Malaysia, which can inform efforts to improve pharmacy practices, design appropriate interventions, and reduce harm to patients.

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