MEDICATION ERRORS

SUMMARY

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Medication errors are the single most preventable cause of patient injury.
They are responsible for about 25% of litigation/medicolegal cases against general
practitioners
The problems, sources and methods of avoiding medication errors are
multifactorial and multidisciplinary

Illegibility, drug name confusion and use of decimal points are common
contributory factors

Medication errors, defined as any error in the prescribing, dispensing or

administration of a drug whether there are adverse consequences or not, are the
single most preventable cause of patient injury.1,2 These errors can occur at any
stage in the drug use process from prescribing to administration to the patient. A
recent report by the Institute of Medicine (IOM) estimated that errors in medical
management cause between 44,000 and 98,000 deaths each year in USA
hospitals.3 In the USA it has been suggested that the rate of serious medication
error is approximately 7%.2 Medication errors are not confined to the hospital
setting. Reports from the Medical Defence Union and the Medical Protection
Society revealed that 25% and 19%, respectively, of legal claims against general
practitioners related to medication errors.4,5

The occurrence of medication errors can compromise patient confidence in the

healthcare system and in addition, increase healthcare costs.6

Economic

consequences may include the award of damages to the patient, extension of a

patients stay in hospital and the potential financial support required for long term
care of a patient who suffers permanent injury.7 In the USA, it has been estimated
that the cost of adverse drug events, a proportion of which are due to medication
errors, was $5.6m per year for a 700 bed teaching hospital.8

Types of Medication Errors

Medication errors can be broadly classified as prescribing, dispensing or drug
administration errors:

Prescribing Errors
Prescribing errors may be defined as an incorrect drug selection for a patient, be it
the

dose,

the

strength,

the

route,

the

quantity,

the

indication,

the

contraindications.9 This definition can be further expanded to include failure to

comply with legal requirements for prescription writing. The prescriber must
specify the information which the pharmacist needs to dispense the drug in the
correct dosage and form and the directions the patient needs to take it safely.10,11 A
study undertaken in the hospital setting by Lesar et al found an error rate of 4
errors per 1000 medication orders. Of the errors with potential for adverse patient
effects, drug allergies accounted for 12.1%, wrong drug name, dosage form or
abbreviation for 11.4% incorrect dosage calculations for 11.1% and incorrect
dosage frequency for 10.8%.12
Dispensing Errors
Dispensing errors are errors that occur 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.13 Studies in the USA have estimated that
dispensing errors occur at a rate of 1-24%.14 Dispensing errors may undermine the
patients confidence in the pharmacist and increase the likelihood of litigation
procedures.15 These errors include the selection of the wrong strength/product.
This occurs primarily when two or more drugs have a similar appearance or
similar name (look-a-like/sound-a-like errors Table 1). The use of computerised
labelling has led to the emergence of transposition and typing errors which are
among the most common causes of dispensing error.13 Other potential dispensing
errors include wrong dose, wrong drug, wrong patient.

Administration Errors
A drug administration error may be defined as a discrepancy between the drug
therapy received by the patient and the drug therapy intended by the prescriber.16
Drug administration is associated with one of the highest risk areas in nursing
practice. The five rights have long been the basis for nurse education on drug
administration i.e. giving the right dose of the right drug to the right patient at the
right time by the right route.16,17 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. Other types of drug administration errors include wrong
administration technique, administration of expired drugs and wrong preparation
administered.

Contributing Factors to Medication Errors

The problems and sources of medication errors are multidisciplinary and multifactorial.9 The action of one individual alone is rarely the solitary cause of a
medication error or incident, rather a variety of contributing factors combine to
cause incidents.

Contributing factors to prescribing error occurrence include:17,18

Illegible handwriting

Inaccurate drug history taking

Drug name confusion (Table 1)

Inappropriate use of decimal points

Use of abbreviations

Use of verbal orders

Irrespective of how accurate or complete a prescription is, it may be

misinterpreted if it cannot be read.

While the prescriber has a professional

responsibility to issue a safe and legible prescription, haste, fatigue or a lack of

understanding of the importance of clear prescribing may contribute to illegibility.
In addition, poorly written prescriptions may delay administration of
medications.6,19,20 Computer generated prescriptions can help reduce the risk of
prescribing errors due to illegible handwriting, although they in turn may give rise
to further problems such as incorrect drug selection. Lack of knowledge of the
prescribed drug, the recommended dose and the patient may also contribute to
prescribing errors.17
Table:1 Drug Names That May Be Confused
Aminophylline

Amitriptyline

Carbamazepine

Carbimazole

Chlorpromazine

Chlorpropamide

Daonil

Danol

Losec

Lasix

Senokot

Seroxat

Inderal

Ipral

Trental

Tegretol

Epilim

Epanutin

One of the most important causes of dispensing errors is confusing the name of
one drug with another (Table 1).10 Lack of knowledge on new medicines and the
use of outdated and/or incorrect references can also be a contributory factor.13
Other factors include poor dispensing procedures with inadequate checking,
unreasonable workloads and poor housekeeping standards. Studies have also
supported an association between dispensing errors and lighting levels,
prescription workload and noise. It is suspected that distractions and interruptions
can lead to performance errors.14 In addition, not challenging unusual doses,
dispensing unfamiliar products, dispensing before seeing a written order may lead
to errors.21
Contributing factors to drug administration errors include failure to check the
patients identity prior to administration and storage of look-a-like preparations
side by side in the drug trolley. Environmental factors such as noise, interruptions
while undertaking the drug round and poor lighting may also contribute to error.
The likelihood of error is also increased where more that one tablet is required to
supply the correct dose or where a calculation to determine the correct dose is
undertaken.

Methods of Minimising Medication Error Occurrence

Medication errors can be prevented by alterations in the system for ordering,
dispensing and administration of drugs.22

The potential for medication error occurrence in the Irish Healthcare system exists
and must be addressed. Ensuring that up-to-date reference sources are available
to healthcare professionals will help to minimise errors due to lack of knowledge.
The use of computerised physician order entry systems have been shown to
reduce medication errors however the use of information technologies will not, on

their own, solve the problem. Other methods of minimising prescribing errors
include:

Ensuring knowledge of a drug before prescribing

Ensuring an accurate drug history is taken

Printing the drug name and patient details clearly on the prescription

Including all details of drug therapy i.e. name of drug, dose, directions,
duration of therapy

Not leaving a decimal point naked. A zero should always precede

expression of values <1 e.g 0.1. Ten-fold errors in dose have occurred due
to the use of a trailing zero.

Avoiding the use of abbreviations e.g. AZT, ISMN, FeSO4, U

Being aware of sound-a-like products20

Information has been published by the Pharmaceutical Society of Ireland for

pharmacists on how to deal with dispensing errors.23

Reductions in dispensing

errors can be helped by:

Ensuring a safe dispensing procedure

Using different brands or separating products that look-a-like

Focusing on the task in hand, keeping interruptions to a minimum and

maintaining their workload at a safe and manageable level

Being aware of high risk drugs e.g. Potassium chloride, cytotoxic agents

Introducing good housekeeping practices13,14,20

Drug administration errors may be minimised by the following:

Checking patients identity

Having dosage calculations checked independently by another healthcare

professional before the drug is administered

Having the prescription, the drug and the patient in the same place so they
can be checked against one another

Ensuring that medication is given at the correct time

Minimising interruptions during drug rounds24

Conclusion
Each healthcare professional shares a responsibility for identifying contributing
factors to medication errors and for using that knowledge to reduce their
occurrence. Both experienced and inexperienced staff may be responsible for
medication errors. A multidisciplinary approach to solving this problem should
be promoted whereby all parties address the issue of reducing medication error
occurrence. Development of a multidisciplinary approach has been slow, possibly
due to the reluctance or unwillingness of the doctor, pharmacist or nurse to admit
to a medication error. It is important that an attitude of no blame is adopted as
incident reports in the past were often used as instruments of punishment, thereby
creating a sense of unfairness and a fear of discipline. Apart from ensuring the
well-being of patients in their care, the increasing risk of medical litigation means
that healthcare professionals cannot ignore a medication error when it occurs.

References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Am J Health-Syst Pharm 1995;52:379-82

BMJ 2000;320:774-7
NEJM 2000;342:1123-5
The MDU Risk Management 1996;1-8
MPS Casebook 1999;9-10
Am J Hosp Pharm1993;50:315-8
Am J Hosp Pharm 1990;47:555-71
JAMA 1997;277:307-11
Am J Hosp Pharm 1993;50:305-14
Prescribers Journal 1999;39:51-8
Int J Pharm Pract 1993;2:176-9
JAMA 1997;277:312-7

13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.

C&D 1997 (Feb);P1-P2

Am J Health-Syst Pharm 1999;56:1319-25
Ir Pharm J 1992 (Feb):55-61
Am J Health-Syst Pharm 1995;52:390-5
Drug Safety 2000;22:321-33
Am J Health-Syst Pharm 1995;52:382-5
Irish Doctor 1997 (Jan):24-48
Medication Errors 1999, Cohen (Ed)
Am J Health-Syst Pharm 1995;52:369-416
Drug Safety 1996;15:303-10
Ir Pharm J 1998 (Jan);11
Nursing Times 1996;92:40-1