Medication error
Dr. Fatima Ahmad
Medication error :
“ A medication error is any preventable event that may cause or lead to
inappropriate medication use or patients harm while the medication is in the control
of the health care professional, patients or consumer”.
Such events may be related to professional practice, health care products,
procedures, and systems including prescribing order, communication, product
labeling, packaging, nomenclature, compounding, dispensing, distribution,
administration, education, monitoring and use.
An adverse outcome does not necessarily have to occur to classify an event as
medication error.
Each medication that is administered must comply with these five
rights to be free of errors.
Right drug
Right route
Right time
Right dose
Right patient
These provide understandable way to identify when medication error occur.
Types of medication errors
Medication errors can be classified in a variety of way depending reason of error. The following
classification focuses on whether error was related to dispensing, administering, prescribing or
patient compliance.
1. Prescribing error
2. Omission error
3. Wrong time error
4. Unauthorized drug error
5. Improper dose error
6. Wrong dosage form error
7. Wrong drug preparation error
8. Wrong administration technique
9. Deteriorated drug error
10. Monitoring error
11. Compliance error
1. Prescribing Error:
“ A clinically meaningful prescribing error occur when , as a result of prescribing decision or
prescribing writing process, there is an unintentional significant
1. Reduction in the probability of treatment being timely and effective
2. Increase in the risk of harm when compared with generally accepted practice.”
It includes:
Duplicate therapy for single indication
Prescribing incorrect dose(too low or too high)
Writing prescription illegibly
Drug allergy not identified
Out of list abbreviation
2. Omission error:
This type of error occur when a patient does not receive a scheduled dose of medication. Failure
to counsel the patient can be reason for omission error.
3. Wrong time error:
This type of error occur when a dose is not administered in accordance with predetermined
administration interval. It is often impossible to be totally accurate and typically 15 to 30
minutes outside interval is acceptable.
4. Unauthorized drug error:
This error can occur when a patient receive a drug that was not authorized by an appropriate
prescriber.
5. Improper dose error:
This error occurs when the dose administered is different than prescribed, assuming that
prescribed dose was appropriate.
6. Wrong dosage form error:
This error occur when a patient receive a dosage form different from prescribed, assuming
the appropriate dosage form was originally ordered.
7. Wrong drug preparation error:
When medications require some type of preparation, such as reconstitution, this type of
error can occur.
8. Wrong administration technique:
These errors occur when a drug is given to a patient inappropriately. An example is when an
intravenously administered agent is given at excessive rate. Wrong technique for inhalers.
9. Deteriorated drug error:
This error occur when drugs are administered that have deteriorated prematurely due
to improper storage conditions.
10. Monitoring error:
This type of error occur when patients are not monitored appropriately either after they
have received a drug or before they received a drug.
11. Compliance error:
This type of error may be a direct result of insufficient patient counseling from
dispensing pharmacist, a prescribing physician or both. Proper patient education and
follow up may play significant role in minimizing this error.
Factors contributing to Medication Errors
There are several factors involved that may contribute to occurrence
of error. These can be
Human related
System related
Medication related
Human related factors:
Provider Patient
• Over-worked
• Under-trained • In a hurry
• Competence • Health literacy level
• Distracted • Do not understand the medication use
• Illness • Trust providers not to make mistake
• stressed
System-Related Factors
• Lack of communication
• Poor workflow
• Disorganized work space
• Inadequate tools to complete work
• Lack of supervision
Medication-Related Errors
• Look-alike medications
• Multiple dosage forms and strengths
• Sound-alike medication
• Clonidine
• Codeine
• Zantac
• Zyrtec
Medication error Risk factors :
• Poor handwriting
• Inexperienced staff
• Challenging patient populations
• Lack of follow-up
• Lack of appropriate monitoring
• Lack of policy enforcement
• Medically complex patients
• Medications requiring calculations
• Environmental factors (noise, poor lighting, interference)
• Poor communication
• Shift work
• Verbal orders
• Interpersonal factors such as external stress
Medication error prevention:
Legible handwriting
Computerized prescription order
Right dose, right drug, right route, right patient.
Check contradictions (drug interactions)
Specify indications for each drug.
Proper dose calculation
Consideration of patient’s age
Consideration of renal and liver function of patient age.
Patient counseling
Add supplemental information
Discuss patient preferences
Proper monitoring
Do not use abbreviations
Outcome or severity: (categorization)
The NCC MERP National Coordinating Council for Medication Error Reporting and Prevention has
proposed a medication error index that serve to categorize error based on severity or outcome of error. This index is divided
into four main categories and nine subcategories.
1. No error
Category A : events that have the capacity to cause error.
2. Error, no harm
Category B: an error occurred but the medication did not reach the patient.
Category C: an error occurred that reached the patient but did not cause harm.
Category D: an error occurred that resulted in need for increased patient monitoring, but caused no harm.
3. Error, harm
Category E: an error occurred that resulted in need for treatment or intervention and caused temporary harm.
Category F: an error occurred that resulted in initial or prolonged hospitalization and caused temporary harm.
Category G: an error occurred that resulted in permanent patient harm.
Category H: an error occurred that resulted in a near-death event (e.g. anaphylaxis and cardiac arrest)
4. Error, death
Category I : an error occurred resulting to patient death.
Medication error reporting:
Institutional reporting:
Individual institutions must develop a reporting system specific to their institution,
designed to meet their specific needs. There are following methods for collecting
reports.
i. Anonymous self-reports: In this system, anyone can detecting or committing an
error can report it without associating their name. It increases the likelihood of
having an error reported.
ii. Incident reports: This type is most commonly used. In this system, errors are
written up as legal reports and are often used to satisfy JCAHO requirements.
iii. Critical-incident technique: This technique uses observation and interviews of
professionals involved in medication error to analyze and identify weakness in
system.
National reporting:
MedWatch :
MedWatch is the Food and Drug Administration’s “Safety Information and Adverse
Event Reporting Program.” This program was developed by FDA. The purpose of this
program is monitoring clinically significant ADEs and problems with medical products.
The ISMP National Medication Errors Reporting Program (ISMP MERP):
is an internationally recognized program for healthcare professionals to share potential or
actual medication errors that occurred at their workplace. Reporting an error or hazardous
condition is simple and confidential.
The National Coordinating Council for Medication Error Reporting and
Prevention (NCC MERP):
is an independent body composed of 27 national organizations.
When to report and who should report.
The best time to report an event is as soon as possible after the occurrence,
and the best individual to report the event is the individual who was involved or
who discovered or observed the event. Institutions should encourage all
employees to report events and not assume the issue is already known to
management.
JCAHO : Joint Commission on Accreditation of Healthcare Organizations.
Independent, not-for-profit organization that sets and enforces standards
for health care quality and safety.
ISMP MERP : Institute for Safe Medication Practices , medication error
reporting and prevention.