Medication Error
Medication error
The goal of drug therapy is the achievement of defined therapeutic outcomes that improve a
patient’s quality of life while minimizing patient risk. With every therapy there must be a risk
which could be known or unknown. These risks are defined as drug misadventures, which
includes both adverse drug reactions (ADRs) & medication errors.
Any preventable event that has the potential to lead to inappropriate medication use or patient
harm during prescribing, transcribing, dispensing, administering, adherence, or monitoring a
drug, is known as medication error (ME).
Medication errors that are stopped before harm can occur are sometimes called “near misses”
or more formally, a potential error.
Evidence that ME is a problem
Medications harm at least 1.5 million people per year
44,000 to 98,000 hospitalized Americans die each year from medical error
Errors cause more death each year than breast cancer, motor vehicle accidents & AIDS
The financial burden : $30 billion to $130 billion annually
Classification of medication errors
The Medication Use System
Major areas or types of medication error are the following
Prescribing error
Transcription error
Dispensing error
Administration error
Monitoring error
Compliance error
Prescribing errors
It is an incorrect drug selection for a patient. Such errors can include the dose, strength, route,
quantity, indication, or prescribing of contraindicated drug. This definition can be further
expanded to include failure to comply with legal requirements for prescription writing i.e it is
an incorrect drug selection for a patient, failure to comply with legal requirements for
prescription writing.
Contributing factors
Illegible handwriting
Inaccurate medication history taking
Confusion with the drug name
Inappropriate use of decimal points
Use of abbreviations (e.g. AZT has led to confusion between Zidovudine &
Azathioprine)
Use of verbal order
Types of prescribing error
Incomplete information on prescription
Dose/strength error
Timing error
Frequency error
Omission of concomitant treatment
Unnecessary drug
Contraindication error
Incorrect drug
Duplication
Interaction error
Allergy error
Quantity error
Formulation error
Generic/brand name error
Transcription errors
This error can occur due to data entry error by the human operator.
Dispensing errors
It is an error that occurs at any stage during the dispensing process from the receipt of a
prescription in the pharmacy through to the supply of a dispensed product to the patient. Studies
have estimated that dispensing errors occur at a rate of 1-24%. These errors include the
selection of the wrong strength/product. This occurs primarily when ≥ 2 drugs have a similar
appearance or similar name (look-a-like/sound-a-like errors).
Types of dispensing error
Dose omission: No dose of the prescribed drug was dispensed or the number of the
dispensed doses was lower.
Medication prescribed without administration schedule or without the quantity to be
administered or concentration or without pharmaceutical form, and that was dispensed.
Dispensed medication with wrong concentration i.e. a concentration lower or higher
than the prescribed.
Excessive dose: 1 or more doses were dispensed beyond the quantity described in the
prescription.
Wrong dispensed medication: a medication was prescribed but another was dispensed
or a nonprescribed medication was dispensed.
Medication dispensed with a wrong pharmaceutical form.
Medication dispensed with labelling problems or with quality deviation.
Administration Errors
This error is defined as a discrepancy between the drug therapy received by the patient & the
drug therapy intended by the prescriber. Drug administration is associated with one of the
highest risk areas in nursing practice.
Drug administration errors largely involve errors of omission where administration is omitted
due to a variety of factors e.g. wrong patient, lack of stock etc. Other types of drug
administration errors include wrong administration technique, administration of expired drugs
& wrong preparation administered etc.
Contributing factors:
Failure to check the patient’s identity prior to administration
Storage of similar preparations in similar areas
Noise, interruptions while undertaking a drug round, & poor lighting
Monitoring errors
Monitoring error could be failure to review a prescribed regimen for appropriateness and
detection of problems, failure to use appropriate clinical or laboratory data for adequate
assessment of patient response to prescribed therapy, failure to recognize & report adverse
reactions, failure to educate patients about potential side effects etc.
Compliance errors
This error can occur due to inappropriate patient behavior regarding adherence to a prescribed
medication regimen.
Reasons for medication errors
Ambiguous strength designated on labels or in packaging
Drug product nomenclature (look-alike or sound-alike names, use of lettered or
numbered prefixes & suffixes in drug name)
Equipment failure or malfunction
Illegible writing
Improper transcription & inaccurate dosage calculation
Inadequately trained personnel
Inappropriate abbreviations
Labeling errors
Excessive workload
Lapses in individual performance
Medication unavailable
Methods used to minimize or reduce medication errors
Prescriber actions
Nurse (administrator) actions
Organizational action
Forcing functions & constraints
• Use pharmacy system that will not fill any order unless allergy information,
patient weight & height are entered
• Use computer order entry with dosage checks
• Remove dangerous IV drugs (e.g. conc. potassium, hypertonic sodium
chloride) from ward stock
• Limit choices of available drugs in pharmacy
• Limit dosage strengths & concentration for each drug
• Mix IVs in the pharmacy
Automation & computerization (Reduce reliance on memory)
• Use drug-drug interaction checking system
• Use computerized order entry
• Use computerized patient information
• Use bar-coding on drugs, containers, medication records, patient wristbands
• Automated dispensing on patient care unit
Standardization & protocol
• No error-prone abbreviations
• Use generic names rather than brand name
• Use standard equipment- one kind of pump or syringe
• Use protocol for complex medication administration e.g. heparin,
chemotherapy
Pharmacy (dispensing) actions
Independent double check orders both on calculation & preparation
Clarify confusing orders
Checking for current patient drug allergy
Dispense medication using unit-dose, ready to administration form whenever
possible
Patient name, generic drug name, patient specific dose on all labels
The role of pharmacists in medication error prevention: recommendation by
ASHP
Pharmacists should participate in drug therapy monitoring
Pharmacists should stay abreast of the current state of knowledge
Pharmacists should make themselves available to prescribers and nurses to offer
information and advice
Pharmacists should be familiar with the medication ordering system and drug
distribution policies and procedures
Pharmacists should never assume or guess the intent of confusing medication orders
When preparing drugs, pharmacists should maintain order and perform one procedure
at a time with as few interruptions as possible.
Before dispensing a medication in non-emergency situations, the pharmacist should
review an original copy of the written medication orders.
Pharmacists should dispense medications in ready to administer dosage forms
whenever possible.
Pharmacists should review the use of auxiliary labels and use the labels prudently when
it is clear that such use may prevent errors (e.g., “shake well,” “for external use only,”
and “not for injection”).
Pharmacists should ensure that medications are delivered to the patient-care area in a
timely fashion after receipt of orders.
Pharmacy staff should review medications that are returned to the department.
Pharmacists should maintain records sufficient to enable identification of patients
receiving an erroneous product.
Pharmacists should counsel patients or caregivers during discharge