Medication Errors
PHARM D PROGRAM
DR. HASSAN BADER
Medication errors
Medication errors are among the most common medical errors, harming at least 1.5 million people
every year. The extra medical costs of treating drug-related injuries occurring in hospitals alone
are at least to $3.5 billion a year, Medication error morbidity and mortality costs are estimated to
run $77 billion dollars per year
What are Medication Errors?
“... 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”.
How Do Medication Errors Occur?
The provision of drug therapy by a medical provider to a patient is a complex process.
Errors can occur at any step along the way, from prescribing to the ultimate provision of the drug to the
patient.
Common causes of medication error include:
incorrect diagnosis
prescribing errors
dose miscalculations
poor drug distribution practices
drug and drug device related problems
incorrect drug administration
failed communication
lack of patient education.
One of the largest causes of therapeutic medication misadventures is:-
(incorrectly prescribed medication).
Preventable errors occur because systems for safely prescribing and ordering
medication are not appropriately used.
• A widely recognized cause of error is illegible handwritten prescriptions.
• Errors may result from insufficient or missing information about co-prescribed medications, past dose-
response relationships, laboratory values and allergic sensitivities.
• Errors in prescribing can occur when an incorrect drug or dose is selected, or when a regimen is too
complex.
• When prescriptions are transmitted orally, sound-alike names may cause error.
• Similarly, drugs with similar-looking names can be incorrectly dispensed when prescriptions are
handwritten.
• Errors may occur because a prescription is never transmitted to a pharmacy, or a prescription is never
filled by the patient.
• Physician sampling of medications can contribute to medication errors due to the lack of both adequate
documentation and drug utilization review.
The term dispensing error refers to medication errors linked to the pharmacy or to whatever health
care professional dispenses the medication.
These include:
errors of commission (dispensing the wrong drug, wrong dose or an incorrect entry into the computer
system)
Errors of omission (failure to counsel the patient, screen for interactions or ambiguous language
on a label).
Errors of potential (detected and corrected prior to the administration of the medication to the
patient)
The three most common dispensing errors are:
1) dispensing an incorrect medication, dosage strength or dosage form
2) miscalculating a dose
3) failing to identify drug interactions or contraindications.
Attitudes About Medication Errors
Medical professionals, including physicians, nurses and pharmacists, do not deliberately commit
medication errors. They are trained to deliver “error free” health care. However, when errors are
discovered, there is an attitude of placing “blame” on the professional(s) involved in the incident.
Formal punishment by the individual’s profession is sometimes administered, resulting in fines,
license suspension or even license revocation. More importantly, the individual may be punished
by the lost respect of his or her fellow health care professionals, which may be even more
devastating than a professional reprimand.
Keys to Error Prevention
Patient Education
Electronic Technology
Internal Quality Control Procedures
Keys to Error Prevention
Patient Education:
Health care professionals must provide adequate patient education about the appropriate use of
their medications as part of any error prevention program. Proper education empowers the
patient to participate in their health care and safeguard against errors.
Some examples of instructions to patients that can help prevent medication errors are:
1. Know the names and indications of your medications
2. Read the medication information sheet provided by your pharmacists
3. Do not share your medications
4. Check the expiration date of your medications and dispose of expired drugs
5. Learn about proper drug storage
6. Keep medication out of the reach of children
7. Learn about potential drug interactions and warnings
Electronic Technology
Bar Coding
Electronic Prescription Record
E-prescribing
Electronic DUR
Automated Medication Dispensing
Internal Quality Control Procedures
Most medication dispensing settings have developed quality evaluation procedures. These
practices provide workflow evaluation and error reporting analyses, which lead to excellent
protection from medication error. These procedures and evaluations have led to several changes
in standard practice for ambulatory pharmacy, generally adopted as acceptable professional
practice.
