Background: Medication errors are a major patient safety concern, particularly during night shifts when healthcare professionals experience fatigue, increased workload, and staff shortages. In Pakistan, these challenges are further intensified by limited resources and weak interprofessional communication, increasing the risk of errors in medication administration.
Aim: This study aimed to assess the occurrence of medication errors during night shifts in KPK Provincial hospitals and examine the role of nurse–pharmacist collaboration in reducing these errors.
Methodology: A quantitative cross-sectional study design was employed in selected private hospitals of KPK. A total of 250 participants, including 150 nurses and 100 pharmacists, were recruited using a convenience sampling technique. Data were collected through a structured self-administered questionnaire and analyzed using the Statistical Package for the Social Sciences (SPSS) version 26, applying descriptive statistics and chi-square tests.
Results: Findings revealed that 41.2% of participants reported medication errors during night shifts. The most common errors included incorrect dosage and improper timing of medication administration. Major contributing factors were staff shortages, heavy workload, fatigue, and communication barriers. A statistically significant association was found between nurse–pharmacist collaboration and reduced medication errors.
Conclusion: Drug mistakes in night shifts have been an issue of concern in hospitals. To some extent, the enhancement of nurse-pharmacist cooperation and better staffing and communication can be used to minimize medication errors and improve patient safety.

Medication errors, Night shift, Nurse-pharmacist collaboration, Patient safety, Hospitals.

Medication errors are avoidable situations that can result in an inappropriate use of medication or health damage to a person under the control of a healthcare facility, patient, or consumer.[1] Night shifts are working hours that are usually planned at late evening hours up to early morning hours when there is low staffing and increased circadian rhythms in healthcare provision. Nurse-pharmacist collaboration is the professional collaboration between nurses and pharmacists that focuses on guaranteeing safe medication administration by means of communication, verification, and clinical support.[2] Among the most important tasks of nurses in hospitals, there is medication administration. Proper preparation of drugs, calculation of the dosage, and monitoring of patient responses entail excellent coordination among medical workers. Low quality of communication and interdisciplinary collaboration can lead to a higher risk of medication-related errors in clinical practice.[3]

Medication errors are the primary international patient safety issue in health care systems. According to reports by international health organizations, medication errors are known to negatively affect the health of millions of patients annually and cause huge healthcare expenditures and preventable deaths.[4] Research has shown that some of the clinical incidents reported in hospitals are due to medication administration errors. The indicators of the developing nations provide evidence that medication errors occur at varying rates because of the variation in staffing, reporting, and clinical load. Studies done in South Asian healthcare facilities have revealed that medication administration errors are common when there are high workloads, especially at night when clinical supervision and resources might be scarce.[3,5]

Night shifts work presents physiological and cognitive problems that affect healthcare performance. Interference with the circadian cycle, exhaustion, and sleeping loss decrease the concentration, attention capacity, and decision-making skills in healthcare professionals.[6] The nurses who have a long night shift might become less alert when handling their complicated medication schedules. Night clinical settings are frequently characterized by a lack of staff and a smaller number of supervisors. The conditions increase the likelihood of medication errors, the preparation of drugs incorrectly, and the slowness of identifying adverse drug reactions.[7]

In hospitals, medication administration is the main responsibility of the nurses. The procedure of the medication administration needs precise decoding of the prescriptions, verifying the dosage of the drugs, the time of administration, and observation of the patient’s reactions. The multitasking duties and heavy workloads contribute to the chances of making mistakes when working at night. Another issue that can face nurses is care interruptions caused by emergency patient care, documentation, and inadequate staffing. This is the case where nurses are exposed to scenarios that can compromise medication safety unless they are well supported in their efforts to collaborate.[8]

The role of pharmacists in ensuring medication safety in healthcare institutions is crucial. Their pharmacological knowledge, understanding of drug interactions, dosage determination, and medication reconciliation skills play an important role in mitigating the risk of medication errors.[9] It is better when nurses and pharmacists work together to improve the prescription verification process and keep a closer eye on dangerous drugs. The relationship between these professionals should be effective in such a way that medication orders are received and correctly administered. Close interdisciplinary cooperation is associated with the enhancement of patient safety and quality of care.[10]

The developing countries have systemic issues with their healthcare systems that impact safe medication practices. The hospitals in Pakistan are often characterized by a large number of patients, a shortage of medical professionals, and a lack of resources. These aspects add more burdens on nurses and limit the possibility of organized cooperation with pharmacists on night shifts. There are also no standardized communication protocols and inadequate clinical pharmacy services, which complicate medication management processes even more. These institutional constraints can become factors that increase susceptibility to medication mistakes.[11]

There is a dearth of studies that examine the correlation between the night shift working pattern and medication errors in the Pakistani hospital environment. The available research has mainly been conducted on general medication safety concerns without addressing the collaborative aspect of nurses and pharmacists in the night clinical practice. The role of interdisciplinary collaboration in medication safety at night shifts is a crucial process to understand how to enhance the quality of healthcare. The knowledge produced by this study can be used to develop hospital policies, enhance communication behavior, and facilitate measures to curb medication errors in Pakistani hospitals.

The study adopted a quantitative cross-sectional research design to identify medication errors on the night shift in Pakistani hospitals and to determine whether nurse-pharmacist collaboration can help reduce medication errors at night. The cross-sectional design enabled the scholar to gather data on the participants at one moment and examine the associations between variables, including the volume of work, communication, exhaustion, and professional collaboration. The research was carried out in the selected KPK Provincial private hospitals offering 24-hour inpatient healthcare services and had active pharmacy departments. Night shifts in these hospitals were usually 8:00 PM to 8:00 AM, and at this time, healthcare professionals have been observed to have more workload, fatigue, and even reduced staffing, which may increase the risk of committing medication errors.

The sampling group included registered nurses and pharmacists who worked in hospitals and were directly involved in the process of medication management. The administration of medication and monitoring of patients were carried out by nurses, whereas the pharmacists oversaw dispensing, checking, and consultation on drugs. The eligibility criteria included that the participants had to be registered nurses or pharmacists employed in the sampled hospitals, had at least one year of night shift work experience, at least six months of clinical work experience, and had to consent to take part in the research. Pharmacists on an exclusive day shift, those with less than six months of clinical experience, interns or students undergoing clinical training, and those who refused to participate were not included. The sample size was estimated as 250 participants, comprising 150 nurses and 100 pharmacists, according to past research findings that gave a prevalence of medication errors at 41% with a 95% confidence level and 5% margin of error. Participants were recruited using a non-probability convenience sampling method, and the participants were available and willing to participate during their duty hours.

Data collection procedure: A structured self-administered questionnaire was used to gather data, as it was created after an examination of available literature on medication errors and interprofessional collaboration within a healthcare environment. The questionnaire had four parts. Section A gathered demographic data, including age, gender, professional designation, and clinical years. Section B investigated the occurrence and nature of medication errors during night shifts (when and where). Section C also evaluated contributing factors to medication errors, including staff shortages, communication gaps, fatigue, and lack of training. Section D was an evaluation of the degree of collaboration between nurses and pharmacists, the nature of communication between the two groups, the role of pharmacists in medication checking, and the perception of teamwork effectiveness as a means of reducing medication errors.

To achieve content validity, the instrument was consulted by the specialists in nursing, pharmacy, and healthcare research before the primary data collection. Clarity and feasibility of the questionnaire and its reliability were evaluated in a pilot study. The level of reliability was tested through the Cronbach alpha coefficient, with the acceptable level being 0.70 or above. Some qualified participants were contacted at their working hours with the consent of hospital officials. Their informed consent was provided in writing, and the purpose of the study was explained to them. The questionnaire was filled out by the participants in their spare time, and the data collection lasted about four to six weeks.

Data analysis procedure: The data that were collected were coded and keyed into the Statistical Package of Social Sciences version 26 to be subjected to statistical analysis. The demographic traits of the participants and their reactions to the items of the questionnaire were summarized using descriptive statistical tools. Categorical variables were calculated in frequencies and percentages, and the continuous variables were calculated in means and standard deviations. These statistics gave an idea of how many medication errors occurred in nurse shifts and perceived the degree of nurse-pharmacist collaboration.

Inferential statistical testing was also carried out to test relationships among variables. The chi-square test served to identify relationships among categorical variables, which are medication error occurrence, workload, communication patterns, and collaboration between nurses and pharmacists. Findings of these analyses served to determine the important factors that cause medication errors on the night shift and the possible influence of interprofessional collaboration on medication safety in hospitals.

Demographic characteristics of participants: Table 1 presents the demographic characteristics of the study participants (n = 250). The majority of participants were aged between 26 and 30 years (40.8%), followed by 21 and 25 years (31.2%), while only 8.8% were over 35 years. In terms of gender distribution, males constituted 53.6% and females accounted for 46.4% of the sample. Regarding the professional category, nurses represented the largest proportion of participants (60.0%), while pharmacists comprised 40.0%. Most respondents had 3-5 years of clinical experience (43.2%), followed by more than five years (31.2%). Concerning night shift experience, 38.4% had 1-2 years of experience, 36.8% had 3-5 years, and 24.8% reported more than five years of experience working night shifts.

Table 1: Demographic characteristics of participants

Table 2 demonstrates the frequency and nature of medication errors that happen during night shifts among health care professionals. The findings suggest that 41.2% of the participants said that they had medication errors during night shifts, and 58.8% had no medication errors. Among the medication errors reported, the most frequent kind was the wrong dose (37.9%), next came the wrong time of administration (27.2%), wrong medication (20.4%), and documentation errors (14.5%). With respect to time of occurrence, most of the medication errors were reported between 12:00 AM and 4:00 AM (44.7%), 29.1% between 4:00 AM and 8:00 AM, and 26.2% between 8:00 PM and 12:00 AM.

Table 2: Prevalence of medication errors during night shifts

Table 3 shows the factors involved in medication errors at night shifts. The participants reported staff shortages as a significant contributing factor 58.4% and 41.6% did not consider staffing to be a problem. Over half of the respondents (55.6%) said they felt high pressure of workload during the night shifts, and 31.2% said they felt moderate workload, and 13.2% said they felt low workload. 63.2% percent of the respondents reported experiencing fatigue during night duty, which is a major issue for night shift performance. 48.4% the respondents reported communication problems, and 51.6% reported no communication problems. Also, 38.8 % of respondents noted the absence of training as one of the causes of medication error, but 61.2% did not believe that training deficiency was a significant problem.

Table 3: Contributing factors to medication errors during night shifts

Table 4 explains the extent of nurse-pharmacist cooperation in medication management at night shifts. The results indicate that 67.2% of the respondents stated that they regularly communicated with pharmacists, whereas 32.8% said that they were not in regular communication with pharmacists. 61.6%. Of the participants reported having pharmacist involvement in medication verification, as opposed to 38.4 % who reported limited participation of pharmacists in medication verification. When questioned about the presence of pharmacists on night shifts, 36.8% said they had pharmacists, and 63.2% said that they did not have pharmacists during the night. Despite this weakness, 68.8% of the respondents felt that a nurse-pharmacist collaboration was effective in minimizing medication errors, whereas 31.2% believed it was ineffective.

Table 4: Nurse-pharmacist collaboration in medication management

Table 5 shows the relationship between nurse-pharmacist cooperation and medication errors at night shifts. The findings indicate that in the group of participants who indicated effective collaboration, 30.2% had medication errors, and 69.8% did not have any errors. Conversely, in individuals who stated that they had poor collaboration, 65.4% of them had medication errors, and 34.6% of those did not have medication errors. The chi-square test revealed that nurse-pharmacist collaboration and medication errors were statistically significant (χ² = 8.47, p = 0.003). This shows that the successful cooperation of nurses and pharmacists is largely linked with reduced medication errors during night shifts.

Table 5: Association between nurse-pharmacist collaboration and medication errors during night shifts

The problem of medication errors on night shifts is a significant patient safety issue in hospitals. The current research determined that 41.2% of the participants indicated that they had made medication errors on night duty. This observation indicates the susceptibility of healthcare systems at night when staffing is low, and the level of fatigue is high among healthcare professionals. The same results were observed in past international research where medication errors were common during night shift because of their decreased alertness and high workload among the nurses.[12] Research performed in the hospital setting also indicated that medication mistakes are rather frequent during the late-night period when healthcare professionals face circadian rhythm distortions and cognitive exhaustion.

The current results indicated that incorrect dosage was the most common kind of medication error that was reported, then came incorrect timing of medication intake and incorrect medication choice. These results are aligned with previous research reports that have reported dosage and time errors as the most prevalent medication administration errors in hospitals.[9] Studies in clinical settings found that dosage mistakes were common due to complicated drug requirements and work overloads among nurses with multiple patients. In other studies, carried out in advanced healthcare systems, it was reported that there were lower rates of dosage errors because of the computerized medication systems and barcode-assisted technologies of medication administration.[13]

The study findings indicated that most of the medication errors happened between 12:00 and 4:00 AM. This is the time when healthcare professionals are most likely to be tired and less vigilant. The previous studies already reported that clinical errors increase early in the morning as healthcare professionals have less concentration and slower decision-making capacity during circadian low phases.[14] The same processes were described in intensive care units, with studies revealing that medication incidents were at their highest during the late night hours when fewer healthcare personnel were available to oversee the medication administration processes.

The current study found staff shortage and high workload as one of the significant factors contributing to medication errors in night shifts. Over half of the participants also indicated that the pressure of work was a factor in medication errors. Earlier studies that have been carried out in hospitals have revealed that Ratios of nurses to patients play an important role in medication safety practices.[15] Research in high-resource health care systems indicated that the right amount of staffing minimizes medication administration errors and enhances patient safety outcomes. Similar results were reported in research carried out in developing health care systems where staffing was minimal, further exposing pressure to nurses tasked with medication administration.

In this study, a high percentage of participants reported fatigue during night shifts, and this shows that night shifts have a great impact on medication safety. Previous literature has drawn attention to the fact that sleep deprivation and high working hours diminish cognitive performance and raise the chances of clinical errors in nurses.[16] Occupational health studies indicated that night shift workers are impaired with respect to their attention, reaction time, and decision-making ability. The studies conducted in hospital environments indicated that nurse fatigue is a major factor in medication administration errors and near-miss incidents.

Most participants reported communication between nurses and pharmacists, but the presence of pharmacists on the night shift in most hospitals was still limited. The importance of interprofessional communication in the prevention of medication errors and in medication safety was highlighted in previous research.[17] Hospitals wherein pharmacists and nurses have organized cooperation showed better medication verification procedures and fewer medication-related incidents. Studies carried out in healthcare systems that had well-developed clinical pharmacy services indicated that pharmacist involvement in drug review contributes greatly to medication accuracy.

The results of this research revealed that nurse-pharmacist collaboration and medication errors were statistically significantly related to each other. Effective collaboration among the participants reported a reduction in medication errors compared to weak collaboration. The same outcomes were found in the literature on interprofessional collaboration in medication management.[18] Hospital-based research revealed that collaborative healthcare models enhance communication, improve medication verifications, and minimize medication administration errors. Research in healthcare facilities where pharmacists were part of the patient care team reported a significant decrease in medication-related adverse events, and thus the need to enhance the role of nurse-pharmacist collaboration in a hospital.

Recommendations:

• Hospital administrations should ensure adequate staffing levels during night shifts to reduce workload pressure and minimize the risk of medication errors among healthcare professionals.
• Healthcare institutions should strengthen nurse–pharmacist collaboration by establishing clear communication channels and encouraging regular interaction between nurses and pharmacists during medication management processes.
• Pharmacist availability during night shifts should be increased, particularly in hospitals with high patient volumes, to support medication verification and clinical decision-making.
• Regular training programs and continuing education sessions should be organized for nurses and pharmacists, focusing on medication safety, drug calculations, and error prevention strategies.
• Hospitals should implement standardized medication safety protocols, including medication administration guidelines and double-checking systems for high-risk medications.

The researchers evaluated medication errors at night shifts in Pakistani hospitals and analyzed how nurse-pharmacist collaboration could help in minimizing the number of medication errors. The results showed that most of the medication errors were reported during the night shift, most of them being wrong dosage and wrong time of drug intake. The most common instances of errors were noted during the midnight to early morning hours, and this indicates the effect of sleepiness and lack of alertness in healthcare professionals. The following factors were perceived as the main causes of medication errors: staff shortages, workload, fatigue, lack of communication, and insufficient training. The findings also showed that there is a strong correlation between nurse-pharmacist collaboration and medication safety since those who reported effective collaboration encountered fewer medication errors. These results demonstrate the significance of the need to enhance staffing ratios, increase the level of interprofessional cooperation, and introduce organized medication safety activities to decrease the number of medication errors and improve patient safety on night shifts in hospitals.

The authors would like to express their sincere gratitude to Dr. Shah Hussain, Principal/Associate Professor, Janbar, College of Nursing, Swat, for his invaluable supervision, guidance, and support throughout the course of this study.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Corresponding Author:
Mian Muhammad Qasim
Department of Nursing
Saidu Teaching Hospital, Swat, Pakistan
Email: mianmuhammadq07@gmail.com

Co-Authors:
Khursheed Ali, Aizaz Ali, Abdul Majeed, Bakh Saif Ur Rahman, Sabir Ullah, Sajjad Karam,
Department of Nursing
Saidu Teaching Hospital, Swat, Pakistan

Shawkat Ali
Department of Nursing
Hasnain College of Nursing and Allied Health Sciences, Swat, Pakistan

Shah Hussain
Department of Nursing
Janbar College of Nursing, Swat, Pakistan

Bashir Ahmad
Department of Pharmacy
Janbar College of Nursing, Swat, Pakistan

Khursheed Ali, Aizaz Ali, and Abdul Majeed contributed to data collection and data analysis. Bakh Saif Ur Rahman and Mian Muhammad Qasim were responsible for data collection and the literature review. Sabir Ullah and Sajjad Karam handled data collection, data organization, and interpretation. Dr. Shawkat Ali, Dr. Bashir Ahmad, and Dr. Shah Hussain contributed to data analysis and interpretation.

Ethical Approval was obtained from the Shifa Hospital, Swat, Ref No SH/IRB/2026/03

The authors declare that there is no conflict of interest regarding the publication of this paper.

Khursheed Ali is the guarantor of this study and takes full responsibility for the integrity of the data and the accuracy of the data analysis.

https://doi.org/10.63096/medtigo3061321

Ali K, Ali A, Majeed A, et al. Medication Errors During Night Shifts in Pakistani Hospitals: Role of Nurse-Pharmacist Collaboration. medtigo J Pharmacol. 2026;3(2):e3061321. doi:10.63096/medtigo3061321 Crossref