Objective: To study the characteristics of ophthalmic prescribing error (OPE), associated factors and the effect of direct personal notification using the Prescription Error Notification System (PENS).

Materials and Methods: A retrospective review was done in the outpatient Ophthalmology department of King Chulalongkorn Memorial Hospital (KCMH) of the written prescriptions of the ophthalmic drugs given between June 2012 and May 2017. The incidence and types of OPE were analyzed and stratified by types of practitioners. After April 2015, PENS was applied to reduce OPE. Odds ratios (ORs) of associated factors that affected OPE and adjusted ORs (AORs) for PENS were calculated.

Results: The five-year incidence of OPE was 0.27% (1781/662382). The three most common types of OPE were unspecified dosage form (25.1%), incorrect abbreviation (15.1%), and incorrect instruction (12.6%). The associated factors of OPE were prescription by residents (AOR 1.753; p<0.001), especially for the first-year residents (AOR 1.884; p<0.001). The preventive factors of OPE included prescription by faculty members (AOR 0.378; p<0.001) and prescription in second half of the year (AOR 0.651; p=0.001). PENS reduced OPE, especially in fellow and staff group.

Conclusion: Ophthalmic trainees trend to have more OPEs than faculty members. Active personal notification using PENS reduces OPE. However, its effectiveness does not sustain more than a year. Continuous surveillance of OPEs and repeated PENS is only effective in the first year. Other strategies are needed to reduce OPE.

Keywords: Ophthalmic prescription error, Outpatient, Ophthalmology, Notification system, Training center, Health quality

Received 2 Jul 2019 | Revised 21 Aug 2019 | Accepted 22 Aug 2019