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INDIRA COLLEGE OF PHARMACY, PUNE

Medication Errors
Assignment
Shubhangi Sanjay Kadam

Pharm D Year V

2020-2021

Clinical Pharmacokinetics and Therapeutic drug monitoring

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Table of Contents

Titles Page
Definition and Classification 3

Examples and case studies 4

Factors that affect medication errors 7

Key issues 8

Medication error index 9

Dangerous abbreviations 11

Medication error reporting form 12

Strategies to reduce medication errors 13

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Medication errors
Definition

• A medication error is defined as "any preventable event that may cause or lead to

inappropriate medication use or patient harm while the medication is in the control of
the healthcare professional, patient, or consumer,” according to the National
Coordinating Council for Medication Error Reporting and Prevention of United States

• Such events may be related to professional practice, health care products, procedures, and
systems, including prescribing, order communication, product labelling, packaging, and
nomenclature, compounding, dispensing, distribution, administration, education,
monitoring, and use

• Estimating the prevalence of medication errors is difficult due to the varying definitions
and classification systems employed

It has been estimated that in some countries approximately 6-7% of hospital admissions appear
to be medication related, with over two-thirds of these considered avoidable and thus, potentially
due to errors .

Classification

There are a number of different approaches to classify medication errors .

One approach is to base the classification on the stage in the sequence of medication use
process:
 prescribing,
 transcribing,
 dispensing,
 administration or monitoring: improper administration technique, wrong time errors

Another approach is to consider the types of errors occurring, such as

 wrong medication,
 dose : omission error, improper dosing errors, wrong dose errors,
 frequency,
 administration route or patient : fragmented care errors

A further approach classifies errors according to whether they occur from mistakes made
 When planning actions (knowledge-based or rule-based mistakes) or
 Errors in the execution of appropriately planned actions (action-based errors, known as
“slips”, or memory-based errors, known as “lapses”)
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Examples of medication errors

1. Prescribing error

Illegible prescription

Case study
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On June 23, 1995, Ramon Vasquez received the following prescription from his cardiologist. He
began taking the medication given to him by the pharmacist on a Saturday morning. By Sunday
night, the medication had affected his heart so much that he had a heart attack. He died several
days later.

Discussion:What is the name of the first drug prescribed? Is it Plendil??? Isordil???

The pharmacist who filled this prescription read it as Plendil. The cardiologist who wrote the Rx
states that he wrote Isordil.

Physician wrote poorly and the indication was not involved in the prescription. Pharmacist did
not question the illegible prescription or the high dose of plendil (max; 10 mg daily)

2. Transcription errors

 Case study

Source : The healthlaw center

A patient was admitted to the hospital for a medical condition that required surgery.  The patient
had a significant past medical history for hyperlipidemia, which is abbreviated as “HLD”.  When
the admitting physician dictated the patient’s medical history, including his history of
hyperlipidemia, the transcriptionist interpreted the dictation of “HLD” as “HIV”.  This
transcription error was discovered when the surgeon advised the patient that special precautions
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were needed in order to perform surgery in light of his history of HIV.  While the hospital freely
admitted to the transcription error, such a mistake could have profound consequences for the
patient’s future medical care.

[Link] errors

Case study

Source: prime (case studies for pharmacists)

A 40yr old female was brought into the ER for shortness of breath and rash following ingestion
of seafood. On presentation she wasfound to have edema of throat with mild stridor upon
inspiration . Her temp was 98.7deg F , BP: 100/169mmhg, PR: 70bpm

Management : supplemental oxygen

0.5mg epinephrine(1:1000)

Complaints:

shortly after iv infusion of epinephrine patient complained of chest pain on left side with
tingling in her fingertips

ECG showed ST elevation and increased serum creatine kinase level consistent with a MI

Management of complaints: 2 doses of 0.4mg sublingual nitroglycerin over next 10 minutes was
given to the patient. Subsequent ECG showed ST levels returned to baseline normalizing BP,HR

Discussion: Investigations revealed ROA was not specified for 0.5 mg epinephrine and hence
patient received drug incorrectly through iv rather than im

[Link] medication
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Beers criteria lays down the categorization of drug which are potentially inappropriate, drugs to
be used with caution , drug drug interactions that should be avoided in older adults.

Indomethacin is one such drug which is a PIM , there is a reported medication error of self
medication of the drug for osteoahritis in an age old female of 80 yrs leading to hyperkalemia,
hyponitremia . (Source: medication use leading to ED evaluation in older adults and review of
beers criteria, Michele B Kaufman, Prime)

Factors that may influence medication errors

Factors associated with health care professionals

Lack of therapeutic training n Inadequate drug knowledge and experience

Inadequate knowledge of the patient
Inadequate perception of risk
Overworked or fatigued health care professionals
Physical and emotional health issues
Poor communication between health care professional and with patients

Factors associated with patients

Patient characteristics (e.g., personality, literacy and language barriers)

Complexity of clinical case, including multiple health conditions, polypharmacy and
high-risk medications

Factors associated with the work environment

Workload and time pressures

Distractions and interruptions (by both primary care staff and patients)
Lack of standardized protocols and procedures n Insufficient resources
Issues with the physical work environment (e.g., lighting, temperature and ventilation)

Factors associated with medicines

Naming of medicines
Labelling and packaging

Factors associated with tasks

Repetitive systems for ordering, processing and authorization

Patient monitoring (dependent on practice, patient, other health care settings, prescriber)

Factors associated with computerized information systems

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Difficult processes for generating first prescriptions (e.g. drug pick lists, default dose
regimens and missed alerts)
Difficult processes for generating correct repeat prescriptions
Lack of accuracy of patient records
Inadequate design that allows for human error

Primary-secondary care interface

Limited quality of communication with secondary care

Little justification of secondary care recommendations

Key issues

Injection use

The prevalence of injection use in primary care varies considerably between geographic regions,

Injection use may be associated with errors not applicable to oral preparations. A primary
concern is the risk of infectious disease transmission. Results from the WHO global burden of
disease study estimated that unsafe medical injections led to 340,000 human immunodeficiency
virus (HIV) infections, 15 million hepatitis B infections and three million cases of bacteraemia in
2008 .

Other errors associated with injection use include mistakes in weight-dependent dosing, incorrect
reconstitution (including the wrong concentration or inappropriate diluent), wrong route of
administration and problems with storage (e.g. inappropriate refrigeration).

Other issues related to injection use include the need for hepatitis B vaccination of health
workers, and adequate facilities and training for the safe disposal of used injection equipment.

Paediatrics

Medication use in children presents some additional challenges. A small error in dose of
medication given to children has a greater risk of harm compared to the adult population.

prescribing also requires weight-related dose adjustment and other dosing calculations, which
are less commonly encountered in adult prescribing. Primary care providers may feel that they
do not have time to properly check doses in relation to a child’s weight, which is subject to
change over time and thus, has the potential to lead to inaccurate prescriptions being written and
dispensed.

Liquid medication in children is also likely to be required, yet reports suggest that over 40% of
carers make errors when dosing liquid medications

Care homes
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The elderly population may also encounter special issues related to medication errors. For
example, people living in care homes are often frail with multiple health conditions and take
multiple medications. The administration of medication in this environment often differs to
patients’ own homes as it is provided by nursing staff or other personnel, thus raising particular
issues around dispensing, administration and monitoring problems, as well as staff training.

A study estimated the prevalence of inappropriate medication use in 15 nursing homes. The
study found that 46.5% of the patients received at least one inappropriate medication and 12.8%
patients experienced at least one adverse health outcome .

Factors contributing to medication errors included patient factors, such as confusion and lack of
knowledge about the medicines, as well as physical problems that made administration of
medications difficult.

There were also task factors, including a lack of prescribing technical support, such as computer
aids and availability of medical records, lack of protocols, inadequate staff experience and
monitored dose systems.

Organizational factors included inaccurate medication administration record charts, poor

communication, busy staff subject to interruptions and distractions and a lack of provider
accountability .

Medication error Index (NCCMERP)

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Dangerous abbreviations

Abbreviation Intended meaning Common Error

U Units Mistaken as a zero or a four (4)

resulting in overdose. Also
mistaken for "cc" (cubic
centimeters) when poorly
written.

µg Micrograms Mistaken for "mg" (milligrams)

resulting in an overdose.

Q.D. Latin abbreviation for every The period after the "Q" has
day sometimes been mistaken for
an " I, " and the drug has been
given "QID" (four times daily)
rather than daily.

Q.O.D. Latin abbreviation for every Misinterpreted as "QD" (daily)

other day or "QID" (four times daily). If
the "O" is poorly written, it
looks like a period or "I."

SC or SQ Subcutaneous Mistaken as "SL" (sublingual)

when poorly written.

TIW Three times a week Misinterpreted as "three times a

day" or "twice a week."

D/C Discharge; also discontinue Patient's

medications have
been prematurely
discontinued when
D/C, (intended to
mean "discharge")
was misinterpreted
as "discontinue,"
because it was
followed by a list
of drugs.
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HS Half strength Misinterpreted as

the Latin
abbreviation "HS"
(hour of sleep).

cc Cubic centimeters Mistaken as "U"

(units) when poorly
written.

AU, AS, AD Latin abbreviation for both Misinterpreted as

ears; left ear; right ear the Latin
abbreviation "OU"
(both eyes); "OS"
(left eye); "OD"
(right eye)

IU International Unit Mistaken as IV

(intravenous) or
10(ten)

MS, MSO4, MgSO4 Confused for one another Can mean

morphine sulfate or
magnesium sulfate

Consumer’s Medication Error Reporting Form

Steps

1. i. Date and Age of the person affected at the time of error or event

ii. Error description

2. i. Place where the event occurred ( hospital/pharmacy/school etc)

ii. Photograph /scan/ image (prescription/product/related documents)

iii. Any additional information

3. i. Email address of the reporter

ii. Option for organization/firm where the information can be shared (ex:FDA/manufacturer)

Healthcare Practitioner’s Medication Error Reporting Form

Types
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[Link] errors

2. Vaccine errors

Medication errors

Steps:

1. Personal details ( Email address mandatory)

2. Description of event/error

3. Causes/contributing factors

4. Risk reduction strategies

5. Copy/scan/image (related documents/prescription/product)

Strategies to reduce medication errors

1. Educating health care providers and patients

Educating primary care providers about common causes of medication errors;

Providing simple tools to assist primary care providers in safe medication prescribing and
use process;
Considering how patients can be actively involved in medicine management;
Providing patient engagement tools to address non-adherence.

2. Implementing medication reviews and reconciliation

Ensuring that pharmacists actively review prescriptions;

Encouraging and supporting use of medication reconciliation by clinicians.

3. Using computerized systems

Strengthening electronic prescribing and alert systems. Computerized provider order

entry with decision support may be particularly effective when targeted at a limited
number of potentially inappropriate medications and when designed to reduce the alert
burden by focusing on clinically-relevant warnings.

4. Prioritizing areas for quick wins

Target use of injections as a key source of errors;

Target interventions related to the care of children and the elderly;
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Implement multicomponent interventions with a mix of education, health informatics,

medication reviews and involvement of community pharmacists;
Consider specialist outpatient clinics for the prescription of selected medications that
require routine monitoring, such as warfarin;
Conduct further research on medication errors to develop a better understanding of the
causes, generate evidence for interventions impacting on adverse outcomes, and to help
bridge knowledge gaps in low- and middle-income countries on injection use and the
specificities of the paediatric population.

 References
Donna Craig () The healthlaw center, Available at: [Link]
study-transcription-error/#:~:text=HIPAA%20Case%20Study%20%E2%80%93%20Transcription
%20Error.%20Posted%20by,history%20for%20hyperlipidemia%2C%20which%20is
%20abbreviated%20as%20%E2%80%9CHLD%E2%80%9D. (Accessed: 1st November 2020).
NCCMERP () About medication errors, Available at: [Link]
medication-errors (Accessed: 1st November 2020).
Prime () Medication error: right drug, wrong route, Available at:
[Link]
_Route (Accessed: 1st November,2020).
Rupert Payne, Sarah Slight, Byoni Dean Franklyn (2016) Medication errors. Publications [Online].
Available at: [Link]
[Link];jsessionid=FC640DB96546117B0935DEAD89EA88D4?sequence=1 (Accessed: 31st
October 2020).