Effects of Injectable Medication Label Development on Medication Errors, Adverse Drug Events, and Medication Wastage Costs at Sungaikolok Hospital

Abstract

Background and Objectives Medication errors and adverse drug events associated with injectable medications are important patient safety concerns, particularly during medication compounding, preparation, and administration. Labels that do not adequately support clinical workflows may increase the risk of errors. This study aimed to evaluate the effects of redesigning injectable medication labels based on Human Factors Engineering (HFE) principles on medication errors, adverse drug events, and medication wastage costs at Sungaikolok Hospital.

Methods A quasi-experimental study with an uncontrolled before-and-after design was conducted. Incident reports from the HRMS were compared between the pre-intervention period (May 1, 2024, to February 28, 2025) and the post-intervention period (March 1 to December 31, 2025). Eligible incident reports involving medication errors or adverse drug events associated with injectable medications were included. The labels were redesigned to support nursing workflows and provide information on routes of administration, drug stability, compatibility, pH, and osmolarity, together with safety warning symbols.

Results The number of reported incidents was lower in the post-intervention period than in the pre-intervention period. The distribution of incident severity levels differed significantly between the two periods (p = 0.025). No level C incidents were reported after the intervention, and the number of level D incident reports decreased from 12 to 8. Reported errors involving medication compounding and preparation, as well as the handling of multiple-dose medications, also decreased. Medication wastage costs decreased from THB 2,662.01 to THB 806.00.

Conclusions and Recommendations Implementation of injectable medication labels development using HFE principles was associated with fewer reported incidents and lower medication wastage costs. These findings suggest that user-centered label design may support medication safety. However, the absence of a control group precludes attributing the observed changes solely to the redesigned labels.