MEDICATION ERRORS
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Definition
According to NCCMERP,
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while
the medication is in the control of the health care professional, patient, or consumer. Such events may be related to
professional practice, health care products, procedures, and systems, including prescribing; order communication; product
labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and
use.
-National Coordinating Council for Medication Error Reporting and Prevention
Such events may be related to:
1. Professional practice.
2. Health care products.
3. Procedures.
4. Prescribing
5. Product labeling
6. Packaging
7. Compounding
8. Dispensing
9. Distribution
10. Administration
11. Education
12. Monitoring
13. Use
Major causes of medication errors;
Missing patient information
▪ Allergies
▪ Age
▪ Weight
▪ Pregnancy etc
Missing drug information
▪ Outdated references etc
Drug name, label, packaging problem
▪ Look/sound alike
▪ Faulty drug identification
Drug storage or delivery problem
Environmental, staffing, workflow
▪ Lighting
▪ Noise
▪ Interruptions etc
Lack of staff education
▪ Lack of patient education
▪ Lack of patient consultation
▪ Non compliance
Lack of physician knowledge
Other causes of medication errors;
Research has illustrated there are 5 errors for every 100 orders
The Institute for safe medication practice (ISMP) reports
▪ 30% of errors are due to deficient knowledge
▪ 20% are caused by patient knowledge
▪ 50% result of poor labeling or drug nomenclature
Other causes of medication errors;
Stress, fatigue, ignorance
Personnel neglect, hesitation
Heavy workload
Inexperience/unfamiliarity with medication
New staff
Insufficient training
Complicated order
Unfamiliarity with patients condition
Faulty communication
Failure to monitor closely
System flaws
Types of Medication errors
1. Prescribing errors
2. Dispensing errors
3. Drug administration errors
4. Monitoring errors
5. Compliance errors
1. Prescribing Errors
Most common type
Accounts for 80%
Use of dangerous abbreviations leads to majority of prescribing errors
LASA (Look alike, sound alike)
Illegible handwriting and verbal orders
Incorrect drug selection ( dose, strength, route, quantity, indication, contraindication etc)
A study suggests that 4 prescribing errors occurs per 1000 medication orders.
Drug allergies
Wrong drug name, dosage form, abbreviation
Incorrect dosage calculations
Incorrect dosage frequency
Contributing factors for Prescribing Errors
Inadequate knowledge
Calculation errors
Complicated dosage regimen
Poor patient history taking
Use of multiple dosage forms/dose
Use of abbreviations
Lack of adequate resources
Different drug formulations available
Excessive interruptions while writing prescriptions
Drug name confusion (look alike sound alike)
Inappropriate use of decimal points
LASA drug list
2. Dispensing errors
Occur at any stage during dispensing process ( from receipt of prescription to supply of product to
patient)
Research estimates that 5% of all prescriptions are dispensed improperly
Reduce patients confidence in pharmacist
Confusion occurs primarily with drugs that have similar name or appearance. Lasix (furosemide) and
Losec (omeprazole)
Contributing factors for Dispensing
Errors
Confusing name of one drug with another
Selection of wrong strength /product
Lack of knowledge on new medicine
Use of outdated/incorrect references
Poor dispensing procedures with inadequate checking
Poor housekeeping standards
Distractions/ interruptions
Dispensing unfamiliar products
Dispensing before seeing a written order
Use of computerised labellings , typing errors, most common cause.
3. ADMINISTRATION
ERRORS
Accounts for 26 to 32% of medication errors
Discrepancy drug therapy received by patient and drug therapy intended by prescriber
Types :
Omission Error (left)
Wrong dose Error
Wrong route Error
Wrong site Error
Wrong rate Error
Wrong dosage form Error
Wrong time Error
Wrong preparation of dose Error
Incorrect administration technique Error
Expired Medication Error
Contributing factors of administration
errors
Failure to check patients identity
Storage of look a like preparations side by side
Environmental factors i.e noise, interruptions, poor lighting while undertaking drug round
Calculation to determine correct dose
4 & 5. Monitoring and compliance errors
Monitoring errors:
Caused by;
Failure to review a prescribed regimen (a prescribed course of medical treatment) for
appropriateness
Failure to use appropriate clinical/ laboratory data to assess patients response to prescribed
therapy
Compliance errors:
Caused by;
Inappropriate patient behavior regarding adherence to prescribed medication regimen (a
prescribed course of medical treatment)
Factors causing medication errors
Factors associated with health care professionals
• Lack of therapeutic training
• 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 causing medication errors
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
• Insufficient resources
• Issues with the physical work environment (e.g., lighting, temperature)
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Perform 5 rights of medication administration every time:
Right patient, right drug, right dosage, tight time, right route.
Some experts have expanded this to;
❑ Right reason for drug
❑ Right documentation
❑ Right to refuse medication
❑ Right evaluation & monitoring
Medication review
Automated information system
Computerized prescription order
Patient education