Lesson 3: Medication Errors
1- Introduction to Medication error
Medication error is any preventable event that may cause or lead to
inappropriate medication use or harm to a patient while the medication
is in the control of the healthcare professional, patient, or consumer.
These errors can occur at any stage of the medication process,
including prescribing, dispensing, administering, and monitoring.
2- Types of Medication Errors
1. Prescribing Errors:
o Incorrect Drug Selection: Prescribing the wrong
medication for a condition.
o Dosage Errors: Incorrect dose, frequency, or duration.
o Route of Administration Errors: Wrong method of
delivering the medication (e.g., oral instead of intravenous).
o Failure to Consider Patient Factors: Ignoring patient
allergies, drug interactions, or other medical conditions.
2. Dispensing Errors:
o Wrong Medication: Dispensing a different drug than
prescribed.
o Incorrect Dosage Form: Providing a tablet instead of a
capsule or vice versa.
o Labelling Errors: Incorrect instructions or missing
information on the medication label.
o Miscommunication: Poor communication between
pharmacy staff and healthcare providers.
3. Administration Errors:
o Incorrect Dosage: Administering too much or too little
medication.
o Wrong Time: Giving medication at the wrong time or
missing a dose.
o Improper Technique: Incorrect method of administering
the medication (e.g., improper injection technique).
o Unauthorized Drug: Administering a medication without
proper authorization or order.
4. Monitoring Errors:
o Lack of Monitoring: Failing to monitor the patient’s
response to the medication.
o Failure to Adjust Dosage: Not adjusting the dose based
on patient response or lab results.
o Ignoring Side Effects: Not recognizing or managing
adverse drug reactions.
3- Common Causes of Medication Errors
• Communication Breakdown: Miscommunication between
healthcare providers, patients, and pharmacists.
• Illegible Handwriting: Poorly written prescriptions that lead to
misinterpretation.
• Sound-Alike/Look-Alike Medications: Medications with similar
names or appearances.
• Complex Medication Regimens: Multiple medications with
complicated dosing schedules.
• Inadequate Education/Training: Lack of proper training for
healthcare providers or patients.
• System Errors: Flaws in the healthcare system, such as poor
workflow, inadequate staffing, or lack of standardized procedures.
Look-Alike Medications:
These medications look similar in packaging, label design, or physical
appearance (size, color, shape):
1. Hydroxyzine and Hydralazine – Both medications come in tablet
form and are often confused due to similar names and packaging.
2. Celebrex (pain/inflammation) and Celexa (antidepressant) – The
packaging and pill color can look similar.
3. Lamictal (anti-epileptic) and Lamisil (antifungal) – Both
medications may be mistaken for each other due to similar
packaging.
4. Plavix (antiplatelet) and Paxil (antidepressant) – These drugs
can have similar packaging and labeling, leading to potential
confusion.
5. Zantac (acid reducer) and Zyrtec (antihistamine) – Both come in
tablet form with similar packaging design.
Sound-Alike Medications:
These medications sound similar when spoken, leading to potential mix-
ups during verbal communication (e.g., phone orders):
• Adderall (ADHD medication) and Inderal (blood pressure
medication).
• Klonopin (anti-anxiety) and Clonidine (blood pressure
medication).
• Lantus (insulin) and Lente (insulin) – These insulin brands are
often confused.
• Alprazolam (anti-anxiety) and Lorazepam (anti-anxiety) – Both
benzodiazepines sound alike and are used for similar conditions.
• Zovirax (antiviral) and Zyprexa (antipsychotic) – These drugs
have similar-sounding names and different indications.
4-Impact of Medication Errors
• Patient Harm: Adverse drug reactions, therapeutic failure,
worsening of the condition, or death.
• Increased Healthcare Costs: Additional treatments,
hospitalizations, and legal expenses.
• Loss of Trust: Erosion of patient trust in healthcare providers
and systems.
• Professional Consequences: Legal actions, loss of licensure, or
disciplinary measures for healthcare providers.
5-Prevention Strategies
• Double-Check System: Implementing checks at each stage of
the medication process to catch errors.
• Use of Technology: Utilizing electronic prescribing, barcoding,
and automated dispensing systems.
• Standardization: Developing standardized protocols and
guidelines for medication administration.
• Education and Training: Regular training for healthcare
providers on safe medication practices.
• Patient Involvement: Encouraging patients to be active
participants in their medication management, including
understanding their prescriptions and verifying their medications.
