Sultan Qaboos University Med J, May 2015, Vol. 15, Iss. 2, pp. e250–256, Epub. 28 May 15 Submitted 24 Oct 14 Revision Req. 2 Nov 14; Revision Recd. 1 Jan 15 Accepted 29 Jan 15 School of Pharmacy, College of Pharmacy & Nursing, University of Nizwa, Nizwa, Oman *Corresponding Author e-mail: jimmy_jose2001@yahoo.com and jimmy.jose@unizwa.edu.om املعرفة واملعتقدات والسلوكيات فيما يتعلق باآلثار الضارة لألدوية عند العمانيني دراسة مستعرضة جيمي خو�سيه، بينا جيمي، موزة املعمرية، ثريا احل�رشمية، حليمة الزدجايل abstract: Objectives: This study aimed to assess the knowledge, beliefs and behaviours of an Omani population with regards to the adverse effects of medicines. Methods: This cross-sectional survey was conducted between February and June 2012. A 17-item questionnaire was designed to assess three aspects: knowledge, beliefs and behaviours related to medicine safety. A total of 740 questionnaires were distributed in three representative governorates of Oman. Median total scores for the three sections were estimated. Associations with participants’ demographic variables and medication histories were also assessed. Results: A total of 618 participants completed the survey (response rate: 83.5%). Many participants (46.4%) believed that side-effects occurred only with high doses of medication and over 30% believed that they did not occur at all with traditional and over-the-counter medicines. The median total score was 19 (interquartile range: 6) out of a maximum of 30. Inadequate knowledge, incorrect beliefs and good behaviours were observed among the participants. There was a significant association between certain demographic parameters (age, educational qualification, history of chronic use of medicines and employment status) and median total scores. Participants reported obtaining additional information on medication safety from various sources, with doctors as the most widely used source. Conclusion: Inadequate knowledge and incorrect beliefs among this Omani population indicate a need for interventions to improve public knowledge and address misconceptions regarding medication safety. These interventions could be initiated on both an individual and public scale, with patient interactions by healthcare professionals and mass education activities targeting the larger population. Keywords: Knowledge; Beliefs; Behavior; Public Health; Drug Side Effects; Adverse Drug Reactions; Medication Adherence; Oman. امللخ�ص: الهدف: هدفت هذه الدرا�سة اإىل تقييم معرفة ومعتقدات و�سلوكيات العمانيني مبا يتعلق باالآثار ال�سارة لالأدوية. الطريقة: اأجريت هذه الدرا�سة ب�سالمة املتعلقة وال�سلوكيات واملعتقدات املعرفة جوانب: ثالثة لتقييم ا�ستبيان يف مادة 17 ت�سميم مت حيث 2012 ويونيو فرباير بني امل�ستعر�سة الدميوغرافية املتغريات مع العالقة اأي�سا قيمت الثالثة. لالأق�سام الدرجات متو�سط وقدر عمان. يف حمافظات ثالث يف ا�ستبيان 740 توزيع مت الدواء. للم�ساركني وتناولهم للدواء. النتائج: اأكمل 618 من امل�ساركني يف اال�ستطالع مبعدل %83.5. اعتقد العديد من امل�ساركني )%46.4( اأن االآثار اجلانبية حتدث فقط نتيجةجرعات عالية من الدواء. اأكرث من %30 اعتقدوا اأناأنها مل حتدث على االإطالق مع االأدوية التقليدية وعلى و�سفة طبية، على التوايل. كانت النتيجة االإجمالية متو�سط 19 )املدى الربعي: 6( من اأ�سل 30 كحد اأق�سى. لوحظت حمدودية املعرفة، املعتقدات غري ال�سحيحة وال�سلوكيات احل�سنة بني امل�ساركني. كان هناك ارتباط كبري بني معايري دميوغرافية معينة )العمر، املوؤهل العلمي، وتاريخ اال�ستخدام املزمن لالأدوية والو�سع الوظيفي( و متو�سط جمموع الدرجات. اأفاد امل�ساركون اأنهم ح�سلوا على معلومات اإ�سافية عن �سالمة الدواء من م�سادر خمتلفة، وكان االأطباء امل�سدر االأكرث�سيوعا. اخلال�صة: حمدوديةاملعرفة واملعتقدات غري ال�سحيحة بني العمانيني امل�ساركني ت�سري اإىل احلاجة اإىل التدخل لتح�سني املعرفة العامة وت�سحيح املفاهيم اخلاطئة فيما يتعلق ب�سالمة الدواء. من املمكن اأن تبداأ هذه التدخالت على م�ستوى االأفراد وعلى النطاق العام عن طريق التفاعل بني املتخ�س�سني يف الرعاية ال�سحية واملر�سى واأن�سطة التثقيف اجلماعي الذي ي�ستهدف عدد اأكرب من ال�سكان. مفتاح الكلمات: املعرفة؛ املعتقدات؛ ال�سلوك؛ ال�سحة العامة؛ التفاعالت ال�سلبية؛ االآثاراجلانبية لالأدوية؛ االلتزام بالدواء؛ عمان. Knowledge, Beliefs and Behaviours Regarding the Adverse Effects of Medicines in an Omani Population Cross-sectional survey *Jimmy Jose, Beena Jimmy, Moza N. S. Al-Mamari, Thuraiya S. N. Al-Hadrami, Halima M. Al-Zadjali Advances in Knowledge - Little is known regarding the knowledge, beliefs and behaviours of the Omani public with regards to the adverse effects of medicines among populations in the wider Middle Eastern region. The results of the present study serve to add new data to the existing literature. Application to Patient Care - The results of this study revealed that members of the Omani public had inadequate knowledge and incorrect beliefs regarding aspects of drug safety. This finding needs to be considered in daily healthcare delivery. - Misconceptions regarding the adverse effect of medicines identified in this study should be addressed both on an individual basis as well as through national campaigns. clinical & basic research Jimmy Jose, Beena Jimmy, Moza N. S. Al-Mamari, Thuraiya S. N. Al-Hadrami and Halima M. Al-Zadjali Clinical and Basic Research | e251 Adverse drug reactions (ADRs) are a significant cause of morbidity and mortality in all areas of healthcare. They can result in a significant financial burden as well as severely impacting patient quality of life.1 In terms of adverse drug events, a recently published study based on hospital data reported overall prevalence rates of 3.22%, 4.78% and 5.64% in England, Germany and the USA, respectively.2 Similarly, a prospective observational cohort study in a paediatric referral centre in the UK found that 17.7% of admitted patients had experienced at least one ADR.3 In the United Arab Emirates (UAE), Saheb Sharif-Askari et al. reported that among patients with heart failure, ADR-related cases accounted for 6.7% of admissions to cardiac units.4 In Oman, a retrospective review reported a prevalence of 4.3% of statin-related hepatic effects among patients.5 Patients are active participants in the drug therapy process; their knowledge greatly influences the way drugs are used and, in effect, the overall safety of drug use. Patients’ misconceptions on drug safety can adversely affect the drug treatment process. In pharmacovigilance, the involvement of every stake- holder, including patients, is of the utmost importance.6 It is essential that patients have adequate knowledge and information about drug risks and efficacy in order to be able to make informed decisions about their medical treatment.7 Patients are becoming more aware of the potential side-effects of drug therapies.8 Moreover, patients and consumers often use a number of sources to obtain information about their medicines and other health-related topics.9,10 Nevertheless, it is the responsibility of health practitioners to ensure that patients are informed users of the medicines prescribed to them.11,12 Most patients expect their physicians to provide detailed information concerning the possible adverse effects of prescribed medication.13 As reported by Cullen et al., patient knowledge of the risks associated with medications is frequently inaccurate and inconsistent.14 Furthermore, poor knowledge and inadequate behaviours with regards to prescription, over-the-counter (OTC) and complementary/alternative medicines (CAM) have been widely reported among patients.9,15,16 A cross-sectional study among members of the public in Ajman, UAE, reported poor knowledge among participants regarding the interaction of OTC and prescription medicines.17 Khanderkar et al. reported a lack of modern scientific beliefs among Omani participants and identified the male gender and illiteracy as predictors of non-scientific beliefs.18 Minimising the impact of adverse-effects depends crucially on the early identification of possible drug reactions by patients and informed knowledge of actions to be taken in response.19 It is therefore to be expected that patients who are better informed are more likely to avoid adverse drug-related interactions, cope with predictable side-effects and recognise potential non-dose-related side-effects.7 With this in mind, it is essential to assess patient knowledge and practices regarding medication safety. Understanding existing drug safety knowledge held by patients/ consumers benefits healthcare providers and helps to refine effective communications of drug safety.20 There are limited published studies from Oman as well as the Middle Eastern region assessing the existing knowledge and practices with regards to drug use and safety among members of the public. Hence, this study aimed to assess the knowledge, beliefs and behaviours of an Omani population with regard to the adverse effects of medicines. Methods This cross-sectional survey was conducted between February and June 2012 in three representative governorates (Al Dakhiliyah, Al-Batinah and Muscat) of Oman. The study population included members of the public from one wilayat of each of the three representative governorates. The estimated sample size used for the study was 600 with a confidence level of 99% and interval of four for an overall estimated Omani population of 2.7 million.21 Three investigators were involved in the distribution of 740 questionnaires. Members of the public were approached at various places, including at schools, government offices and in their homes in the wilayats of Samail (Al-Dakhiliyah), Saham (Al-Batinah) and Bawshar (Muscat) by one investigator. Participants were enrolled in the study using quota sampling by age and gender followed by convenience sampling methods. Inclusion criteria included participants over the age of 21 years who were neither healthcare practitioners nor students in any medical or health-related field. A modified Arabic version of a questionnaire from a similar study conducted in Malaysia was used.15 The self-administered questionnaire had 17 items designed to assess three aspects of medication safety: - While Omanis claim to have good behaviours with regards to medication safety, it is important that healthcare professionals continue to share information regarding the potential adverse effects of drugs prescribed or taken by their patients. Knowledge, Beliefs and Behaviours Regarding the Adverse Effects of Medicines in an Omani Population Cross-sectional survey e252 | SQU Medical Journal, May 2015, Volume 15, Issue 2 knowledge (n = 7), beliefs (n = 5) and behaviours (n = 5). Additionally, the questionnaire included a section designed to obtain demographic information as well as details on history of medication usage and personal experience with side-effects. The initial English version of the questionnaire was translated into Arabic. To ensure appropriate translation, it was further retranslated into English by another translator before being pilot tested on 30 participants. No difficulties in understanding or answering the questions were reported by the respondents of the pilot study. This Arabic version of the questionnaire was then used without any further modifications. For a minority of participants, the questionnaire was filled in by the investigator (e.g. in cases of illiteracy). Investigators remained on hand while participants were completing the survey for any required clarifications. The majority of the questionnaire responses were scored using a three-point Likert scale (agree, unsure or disagree). Two of the questions did not follow the Likert scale. Subsequently, responses to these questions, in the three sections of knowledge, beliefs and behaviours, were assessed by estimating the percentage of respondents choosing each response. Scores of 2, 1 and 0 were used for correct, unsure and incorrect responses, respectively, following the Likert scale.15 Median scores were then estimated for each section, with a maximum score of 14, 8 and 8 for the knowledge, beliefs and behaviours sections, respectively, and a minimum score of 0. In addition, median total scores were estimated based on responses to all three sections, with a maximum score of 30 and a minimum score of 0. A score of >80% of the possible maximum score was considered good, 60–80% was considered moderate and <60% was considered poor. The median total scores of the participants were correlated with selected demographic variables in order to determine associations, including gender, age group, educational qualification, employment status, history of medication usage or previous experience with side-effects. Statistical analysis of the data was conducted using the Statistical Package for the Social Sciences (SPSS), Version 15 (IBM, Corp., Chicago, Illinois, USA). The Mann-Whitney U test was used for analysing the difference in median total scores as well as median knowledge, belief and behaviour scores when evaluation was based on more than two groups (gender and chronic use of medicine status). Similarly, the Kruskal-Wallis test was used when evaluation was based on more than two groups (age, educational status, history of experiencing side-effects and employment status). A P value of <0.05 was considered statistically significant. Ethical approval for this study was obtained from the Research Committee of the College of Pharmacy & Nursing, University of Nizwa, Oman. Results A total of 618 participants completed the survey, giving a response rate of 83.5%. The demographic characteristics of the participants and associations Table 1: Demographic variables and associations with median total scores assessing knowledge, beliefs and behaviours with regard to the adverse effects of medicines among an Omani population (N = 618) Demographic variable n (%) Median total score (IQR) P value Gender 0.311 Male 293 (47.4) 18 (5.15) Female 325 (52.6) 19 (5) Age group in years <0.001 18–30 156 (25.2) 20 (4.75) 31–45 156 (25.2) 19 (95) 46–60 132 (21.4) 18 (5.75) 61–75 127 (20.6) 18 (4) >75 47 (7.6) 18 (4) Educational qualification <0.001 No education 130 (21.0) 18 (4) Primary 111 (17.9) 18 (5) Secondary 135 (21.8) 19 (5) Higher secondary 93 (15.0) 19 (5) Higher education 149 (24.1) 22 (6) Chronic use of medicines 0.001 Yes 283 (45.8) 18 (5) No 335 (54.2) 19 (5) Experienced side-effects 0.090 Yes 161 (26.1) 18 (4) No 277 (44.8) 19 (5) Unsure 180 (29.1) 18 (5) Employment status <0.001 Employed 228 (36.9) 19 (5) Self-employed 106 (17.2) 18 (4.25) Unemployed 183 (29.6) 18 (4) Student 101 (16.3) 20 (4) IQR =interquartile range. Jimmy Jose, Beena Jimmy, Moza N. S. Al-Mamari, Thuraiya S. N. Al-Hadrami and Halima M. Al-Zadjali Clinical and Basic Research | e253 with median total scores assessing knowledge, beliefs and behaviours are shown in Table 1. A total of 26.1% of participants reported previously experiencing adverse effects from medicines. The median total score based on the responses to all sections was 19 (interquartile range [IQR]: 6) out of a possible maximum score of 30, which constituted a moderate score. Individual median scores in the knowledge, beliefs and behaviours sections were 8 (IQR: 4), 4 (IQR: 2) and 7 (IQR: 3), out of maximum scores of 14, 8 and 8, respectively. This indicated poor knowledge, poor beliefs and good behaviour scores among the participants. Significant associations were observed between the median total score and age, educational qualification, history of chronic use of medicines and employment status [Table 1]. Participants’ responses to selected questionnaire items in the knowledge, beliefs and behaviours sections are presented in Table 2. Many participants (46.4%) were under the impression that side-effects occured only when using medication in high doses. Furthermore, 34.3% and 37.3% of the participants believed that traditional and OTC medicines, respectively, did not cause side-effects at all. The majority (59.9%) believed that medicines prescribed by doctors were completely safe. The vast majority (71.7%) of the participants claimed that they informed consulting doctors regarding any history of allergies or the use of traditional medicines [Table 2]. Almost all of the selected demographic variables were found to have a significant association with median knowledge scores, except gender. However, only educational qualification was significantly associated with median belief score, while the median behaviour score was influenced by educational qualification and a personal history of experiencing side-effects [Table 3]. Most of the participants (56.1%) reported that they expected healthcare professionals to provide comprehensive information regarding side-effects and medication safety. Participants also reported obtaining additional information on medication safety and adverse effects from various sources, with consulting a doctor being the most widely used method (59.7%) followed by consulting a pharmacist (33.9%) [Table 4]. Discussion In recent years, ensuring that patients are active partners in drug therapies has become a priority. As demonstrated by Jha et al., well-informed patients are more likely to play an active role in drug therapy, thereby influencing its outcome and practice.22 Understanding the existing knowledge, beliefs and behaviours of the public regarding drug safety- related issues can therefore be beneficial in attaining safer drug utilisation among members of the public. In the present study, over a quarter of the Omani participants reported having previously experienced adverse effects from medications. This was similar to results from a study conducted by Hughes et al. in the UK which indicated that a number of patients had experienced ADRs.9 Alarmingly, a good number of participants in the current study were under the impression that both traditional and OTC medicines could not cause adverse effects at all; a similar study conducted in Malaysia by Jose et al. also reported misconceptions regarding the safety of these agents.15 In the USA, Wilcox et al. observed that 46% of exclusive OTC users believed that these medications were safe.16 In contrast, a high level of awareness on the potential abuse, and the safety and effectiveness, of OTC medicines was observed in Tanzania.23 In the Middle Eastern region, a study conducted among the Kuwaiti public found that 61.4% of participants considered natural herbal products to be safe due to the fact that they were made from natural ingredients.24 Due to the wide-spread nature of these misconceptions, it is imperative that members Table 2: Responses to selected questionnaire items assessing knowledge, beliefs and behaviour on drug safety among an Omani population (N = 618) Questionnaire item Response n (%) Agree Unsure Disagree Knowledge Side-effects occur only with high doses of medicine 287 (46.4) 181 (29.3) 131 (21.2) Traditional medicines do not cause any side-effects 212 (34.3) 254 (41.1) 152 (24.5) Over-the-counter medicines* do not cause any side-effects 231 (37.3) 246 (39.8) 141 (22.8) Beliefs Medicines prescribed by a doctor are completely safe 370 (59.9) 140 (22.7) 108 (17.5) Doctors are responsible for any side-effects caused by prescribed medicines 359 (58.1) 165 (26.7) 94 (15.2) Behaviours I normally tell my doctor if I am using traditional medicines 443 (71.7) 97 (15.6) 78 (12.6) I try to obtain additional information before taking a new medication 484 (78.3) 68 (11.0) 66 (10.7) *Medicines bought without a prescription. Knowledge, Beliefs and Behaviours Regarding the Adverse Effects of Medicines in an Omani Population Cross-sectional survey e254 | SQU Medical Journal, May 2015, Volume 15, Issue 2 of the public be educated regarding OTC medicines, the safety of these medications and potential adverse effects. Necessary caution needs to be exercised while using traditional medicines with due consideration of potential interactions with other medications (e.g. interactions between traditional medicines and diseases and between traditional medicines and other drugs). In the current study, the majority of respondents believed that medicines prescribed by a doctor were completely safe, which suggests that members of the public put great confidence in physician management. Furthermore, most respondents expected doctors and pharmacists to provide comprehensive safety-related information. This was similar to results observed in a Canadian study by Nair et al.25 Additionally, these results corresponded with those of earlier studies with patients reporting that inadequate information about drugs and a lack of monitoring were important causes of ADRs.19 The overall median knowledge score observed in the present study was low in contrast to a study in Malaysia where a moderate knowledge score was observed.15 However, the median behaviour score of the participants was good. This is encouraging as it Table 3: Demographic variables and associations with median knowledge, belief and behaviour scores with regard to the adverse effects of medicines among an Omani population (N = 618) Demographic variable Median knowledge score (IQR) P value Median belief score (IQR) P value Median behaviour score (IQR) P value Gender 0.504 0.815 0.834 Male 8 (4) 4 (2) 7 (3) Female 8 (4) 4 (2) 7 (2) Age group in years <0.001 0.601 0.258 18–30 9 (4) 5 (2) 7 (2) 31–45 8 (4) 4 (2) 7 (2) 46–60 7 (4) 4 (2) 7 (3) 61–75 7 (3) 5 (2) 6 (3) >75 6 (3) 4 (2) 8 (2) Educational qualification <0.001 0.005 0.015 No education 7 (3) 4 (2) 7 (3) Primary 7 (4) 4 (2) 6 (3) Secondary 8 (3) 4 (2) 7 (3) Higher secondary 8 (4) 4 (2) 7 (3) Higher education 9 (4) 5 (2) 8 (2) Chronic use of medicines <0.001 0.471 0.058 Yes 7 (3) 4 (2) 7 (3) No 8 (4) 4 (2) 7 (2) Experienced side-effects 0.001 0.410 0.013 Yes 7 (3) 5 (2) 8 (3) No 8 (4) 4 (2) 7 (2) Unsure 8 (4) 4 (2) 6 (3) Employment status <0.001 0.706 0.421 Employed 8 (4) 4 (2) 7 (2) Self-employed 7 (3) 4 (2) 7 (3) Unemployed 7 (3) 4 (2) 7 (3) Student 9 (3) 5 (2) 7 (2) IQR =interquartile range. Jimmy Jose, Beena Jimmy, Moza N. S. Al-Mamari, Thuraiya S. N. Al-Hadrami and Halima M. Al-Zadjali Clinical and Basic Research | e255 shows that members of the Omani public are aware of the importance of informing doctors about their allergy and side-effect history as well as informing them of any concomitant use of traditional and/or OTC medicines. In contrast, the results observed in a study conducted in Taiwan found that the majority of participants did not inform their doctor or pharmacist about their current medications.26 A study conducted among members of the public in Saudi Arabia observed that only a minor percentage of participants discussed CAM use with their physicians.27 The majority of the participants in the present study reported that they expected to be informed of all possible adverse effects of medications; this was in line with other studies.13,25 Moreover, most participants considered their doctor to be the primary source of their information on side-effects; pharmacists were considered to be the secondary source of information. This finding indicates that improving patient-pharmacist interactions is an important priority and should be given due consideration. Patients should be more confident in interacting with pharmacists regarding drug-related information as these healthcare professionals have expertise in this field. Nair et al. demonstrated that Canadian patients considered pharmacists to be the most accessible source of drug-related information.25 Based on a study conducted in Abu Dhabi, UAE, Fahmy et al. reported that pharmacists need more education on drug indications, interactions and adverse events as well as precautionary education on the use of herbal products.28 However, pharmacists in Thailand recommended that drug safety education be provided directly to patients, especially those who are considered to be high-risk.29 In the UK, Hughes et al. reported that patient information leaflets were rarely used by patients, despite their wide availability.9 Significant associations were observed in the current study between median total scores and age, educational qualification, history of chronic use of medicines and employment status. Younger participants (under 45 years old) were found to have a higher score in comparison to their older counterparts. Furthermore, younger participants had greater knowledge and belief scores, although this did not extend to their behaviour scores. Further, as might be expected, participants with a secondary school education or higher demonstrated better scores in all sections (knowledge, beliefs and behaviours), as those with a higher education qualification had the highest scores. However, no significant associations were observed between median belief scores and a history of experiencing side-effects; this was at odds with results observed by Jose et al. in Malaysia.15 This study had the following limitations. The use of a convenience sample instead of a random sample should be considered as a possible source of bias in the sample selection. In order to accommodate the general public and ensure the questionnaire was easy to answer, a 3-point Likert scale was used instead of a more objective 5-point Likert scale. Additionally, even though the number of participants who required the interviewer to respond to the questionnaire on their behalf was limited, the possibility of interviewer bias among these cases needs to be considered. Furthermore, caution needs to be exercised in interpreting the findings related to behaviours as questionnaire responses were self-assessed by participants and therefore may not always reflect real practices. Finally, there were limited responses from members of the public who were over 75 years old. Collecting data from individuals of this age group is important considering that this group is likely to use more medications. As such, further studies are recommended in this field. Conclusion This study evaluated the knowledge, beliefs and behaviours regarding the adverse effects of medicines among an Omani population. Members of the public were found to underestimate the risk of side-effects when using traditional and OTC medications. There is, therefore, a need for educational interventions to improve public knowledge and address misconceptions regarding medication safety. On the other hand, participants reported several encouraging Table 4: Responses to selected questionnaire items assessing expectations regarding side-effect-related information and sources of information among an Omani population (N = 618) Questionnaire item Response n (%) I expect healthcare professionals to inform me regarding: All possible side-effects 347 (56.1) Severe side-effects 263 (42.5) Common side-effects 175 (28.3) Patient identifiable side-effects 142 (22.9) Predictable side-effects 184 (29.7) Sources of information Asking the doctor 369 (59.7) Asking the pharmacist 210 (33.9) Information leaflet 195 (31.5) Internet 70 (11.3) Family members or friends 145 (23.4) Knowledge, Beliefs and Behaviours Regarding the Adverse Effects of Medicines in an Omani Population Cross-sectional survey e256 | SQU Medical Journal, May 2015, Volume 15, Issue 2 drug safety-related behaviours. However, these behaviours need to be objectively observed and assessed in actual drug use situations in order to verify self-reported findings. Furthermore, this study found that participants expected comprehensive information regarding medication safety to be shared by healthcare professionals. Effective communication on drug side- effects between healthcare professionals and patients is recommended as well as obtaining patient histories on their use of alternative and OTC medications. c o n f l i c t o f i n t e r e s t The authors declare no conflicts of interest. References 1. Szymusiak-Mutnick B. Adverse drug reaction reporting. In: Shargel L, Mutnick AH, Souney PF, Swanson LN (Eds). Comprehensive Pharmacy Review. 6th edition. Philadelphia, Pennsylvania, USA: Lippincott Williams & Wilkins, 2007. Pp. 482–90. 2. Stausberg J. International prevalence of adverse drug events in hospitals: An analysis of routine data from England, Germany, and the USA. BMC Health Serv Res 2014; 14:125. doi: 10.1186/1472-6963-14-125. 3. Thiesen S, Conroy EJ, Bellis JR, Bracken LE, Mannix HL, Bird KA, et al. Incidence, characteristics and risk factors of adverse drug reactions in hospitalized children: A prospective observational cohort study of 6,601 admissions. BMC Med 2013; 11:237. doi: 10.1186/1741-7015-11-237. 4. Saheb Sharif-Askari N, Syed Sulaiman SA, Saheb Sharif-Askari F, Hussain AA. Adverse drug reaction-related hospitalisations among patients with heart failure at two hospitals in the United Arab Emirates. Int J Clin Pharm 2015; 37:105–12. doi: 10.1007/ s11096-014-0046-3. 5. Jose J, Al-Tamimi FA, Helal MM, Jimmy B, Al Riyami Q. Statin associated hepatic adverse effects: A retrospective review from a regional hospital in Sultanate of Oman. Oman Med J 2014; 29:351–7. doi: 10.5001/omj.2014.93. 6. Elkalmi R, Hassali MA, Al-Lela OQ, Jawad Awadh AI, Al-Shami AK, Jamshed SQ. 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