PAPER J R Coll Physicians Edinb 2007; 37:343–346

© 2007 Royal College of Physicians of Edinburgh

Medication errors
DJP Williams
Consultant clinical pharmacologist, Department of Clinical Pharmacology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland, UK

ABSTRACT Medication errors, broadly defined as any error in the prescribing, Published online July 2007
dispensing, or administration of a drug, irrespective of whether such errors lead
to adverse consequences or not, are the single most preventable cause of patient Correspondence to DJP Williams,
harm. Medication errors may be classified according to the stage of the Department of Clinical
medication use cycle in which they occur (prescribing, dispensing, or Pharmacology, Aberdeen Royal
Infirmary, Foresterhill, Aberdeen,
administration) although a recent classification of medication error into mistakes, Scotland, UK
slips, or lapses has been proposed. Incidences of medication error rates vary
widely, as a result of the variety of different study methods and definitions used. tel. +44 (0)1224 551 153
The majority of medication errors occur as a result of poor prescribing and often
involve relatively inexperienced medical staff, who are responsible for the majority fax. +44 (0)1224 551 152
of prescribing in hospital. Electronic prescribing may help reduce the risk of
prescribing errors owing to illegible handwriting, although such systems can in turn e-mail [email protected]
lead to further problems such as incorrect drug selection, and their effect on
patient outcomes requires further study. A multidisciplinary approach to solving
the problem of medication errors is required which adopts an attitude of ‘no
blame’, since incident reports have often been used as instruments of punishment,
thereby creating a fear of discipline. This fear may be lessened by creating an open
and safe environment for detecting and reporting medication errors. Current
approaches to preventing medication errors are inadequate and require a shift in
emphasis to a scientific investigation of preventable patient harm.

KEYWORDS Adverse drug event, medication error, patient safety

CME
LIST OF ABBREVIATIONS Adverse drug event (ADE), Institute of Medicine (IOM),
National Patient Safety Agency (NPSA)

DECLARATION OF INTERESTS No conflict of interests declared.

The National Patient Safety Agency Report 2004 (UK) Medication errors can occur at any stage of the
and the IOM Report 2000 (USA) both highlighted that medication use process and may or may not lead to an
medical errors cause a large number of deaths each year. ADE. Depending on the clinical setting, about one-third
These reports recognised that the majority of errors to one-half of ADEs are associated with medication
were not the result of reckless behaviour on the part of errors. The relationship between ADEs, potential ADEs,
health care providers, but occurred as a result of the and medication errors is shown in Figure 1.
speed and complexity of the medication–use cycle.
Medication errors are the single most preventable cause INCIDENCE OF MEDICATION ERRORS
of patient harm. Medication errors are broadly defined as
any error in the prescribing, dispensing, or administration Incident rates of medication errors vary widely, the
of a drug, irrespective of whether such errors lead to reason for which can be explained by the different study
adverse consequences or not. The landmark IOM report methods and definitions used. The rate of medication
estimated that errors in medical management lead to errors varies between 2 and 14% of patients admitted to
between 44,000–98,000 deaths in the US each year hospital, with 1–2% of patients in the US being harmed as
although these figures have been questioned. a result, and the majority are due to poor prescribing.
Medication error has been estimated to kill 7,000 patients
One of the difficulties in this field is the variety of terms per annum and accounts for nearly 1 in 20 hospital
used in the definition and classification of medication admissions in the US. The incidence is likely to be similar
errors. A more recent definition of medication error as in the UK. Medication errors (7% of all incidents) were
‘A failure in the treatment process that leads to, or has the second most common incident reported (after
the potential to lead to, harm to the patient’ has recently patient falls) in a recent National Audit Commission
been proposed, along with a psychological approach to report on patient safety.
the classification of medication errors according to
whether they are mistakes, slips, or lapses.

343
 DJ Williams

PRESCRIBING ERRORS
Prescribing errors may be defined as the incorrect drug
selection for a patient. Such errors can include the dose,
quantity, indication, or prescribing of a contraindicated
drug. Lack of knowledge of the prescribed drug, its
recommended dose, and of the patient details contribute
to prescribing errors. Other contributing factors include:

• Illegible handwriting.
• Inaccurate medication history taking.
• Confusion with the drug name.
• Inappropriate use of decimal points. A zero should
always precede a decimal point (e.g. 0·1). Similarly,
tenfold errors in dose have occurred as a result of the
FIGURE 1 Relationship between ADEs, potential ADEs, and use of a trailing zero (e.g. 1·0).
medication errors. (Reproduced with permission from
• Use of abbreviations (e.g. AZT has led to confusion
Morimoto T, Gandhi T, Seger A, Hsieh T, Bates D. Adverse
drug events and medication errors: detection and between zidovudine and azathioprine).
classification methods. Qual Saf Health Care 2004; • Use of verbal orders.
13:306–14.)
In a four-week UK prospective study of 36,200
CLASSIFICATION OF MEDICATION ERRORS prescriptions, 1·5% were found to have a prescribing error,
25% of which were potentially serious. When only serious
The multiple steps in the medication chain, from when a errors were examined, 58% of the errors originated in the
drug is prescribed to when a patient receives the drug, prescribing decision and 42% in medication order writing.
leads to significant scope for error. However, significant This distribution is different from that seen in non-serious
improvements can be achieved from the prevention of errors. Of further concern was the fact that the majority
CME

medication errors, in terms of reduced patient morbidity, of errors were made by relatively junior medical staff, who
length of hospital stay, and healthcare costs. A are responsible for the majority of prescribing in hospitals.
classification system based on a psychological approach Medical graduates themselves feel unprepared to
has been proposed which allows one to identify broad prescribe shortly after graduation, emphasising the need to
categories of error, quantify them, and develop an ensure sufficient education in prescribing skills. Using a
intervention to prevent them. This classification system human error approach, Dean et al. suggested that most
divides errors into mistakes, slips, or lapses (see Figure 2). mistakes were made as a result of slips in attention, or
because prescribers did not apply relevant rules. Risk
Mistakes may be defined as errors in the planning of an factors for the development of prescribing errors such as
action and may be knowledge-based (e.g. giving a work environment, workload, whether prescribing for
medication without having established whether the own patient, communication within the team, physical and
patient is allergic to that medication) or rule-based. Rule- mental well being, and lack of knowledge were all
based errors can further be classified as either the identified. Organisational factors such as inadequate
misapplication of a good rule (e.g. injecting a medication training, low perceived importance of prescribing, a
into the non-preferred site) or the application of a bad hierarchical medical team, and an absence of self
rule or the failure to apply a good rule (e.g. using awareness of errors also contributed to these errors. In
excessive doses of a drug). Slips and lapses are errors in primary care the rate of prescribing errors has been
the performance of an action – a slip through an estimated to be 11%. Communication of prescribing
erroneous performance (e.g. writing the more familiar information between primary and secondary care has also
‘chlorpropramide’ instead of ‘chlorpromazine’) and a lapse been shown to be less than ideal as evidenced by a study
through an erroneous memory (giving a drug that a which estimated that 50% of patients were failing to take
patient is already known to be allergic to). Technical the correct medicine one month after discharge.
errors are the result of a failure of a particular skill (e.g. in
the insertion of a cannula) and are therefore a subset of Electronic prescribing may help to reduce the risk of
slips (skill-based errors). prescribing errors resulting from illegible handwriting,
although it can in turn lead to further problems such as
Medication errors may also be classified according to incorrect drug selection. Computerised physician order
where they occur in the medication use cycle, i.e. at the entry systems eliminate the need for transcription of
stage of prescribing, dispensing, or administration of a drug. orders by nursing staff and for interpretation of orders by
pharmacy staff and have been shown to have a significant
effect on reducing medication errors. However, the

344 J R Coll Physicians Edinb 2007; 37:343–346

© 2007 RCPE
 Medication errors

ERRORS
When actions are intended but not performed

MISTAKES SKILL-BASED ERRORS (slips and lapses)

Errors in planning actions Errors in executing correctly planned actions

1. Knowledge-based 2. Rule-based 3. Action-based 4. Memory-based

errors errors errors (slips) errors (lapsed)

2a. Good rules 2b. Bad rules or failure 3a. Technical errors
misapplied to apply good rules

FIGURE 2 The classification of medication errors based on a psychological approach. (Reproduced with permission from Ferner
RE, Aronson J. Clarification of terminology in medication errors. Definitions and classification. Drug Saf 2006; 29:1011–22.)

effects of such systems on patient outcomes remain therapy intended by the prescriber. Drug administration
understudied and, when studied, provide variable results. has long been associated with one of the highest risk
areas in nursing practice, with the ‘five rights’ (giving the
DISPENSING ERRORS right dose of the right drug to the right patient at the right
time by the right route) being the cornerstone of nursing
Dispensing errors occur at any stage of the dispensing education. Drug administration errors largely involve
process, from the receipt of the prescription in the errors of omission where the drug is not administered for
pharmacy to the supply of a dispensed medicine to the a variety of reasons. Other types of drug administration
patient. Dispensing errors occur at a rate of 1–24 % and errors include an incorrect administration technique and
include selection of the wrong strength or product. This the administration of incorrect or expired preparations.
occurs primarily with drugs that have a similar name or

CME
appearance. Lasix® (frusemide) and Losec® (omeprazole) The intravenous route of administration is a particularly
are examples of proprietary names which, when hand- complex process during which errors frequently occur and
written, look similar and further emphasise the need to is associated with significant risk to patients as some have
prescribe generically. In the US, the Food and Drug died as a result of the administration of cytotoxic drugs
Administration has insisted that the proprietary name of intrathecally instead of intravenously. The result has been
Losec® be changed as a result of a number of fatalities that the Department of Health has made this particular
associated with this confusion. Elsewhere, the name type of error one of its prime targets in increasing patient
Losec® remains. Other examples of pairs of drugs with safety. A recent study of intravenous drug administration
similar names where confusion occurs include amiloride 5 suggested an error rate of 50% in either the preparation of
mg and amlodipine 5 mg tablets. Other potential the drug or its administration. The most common type of
dispensing errors include wrong dose, wrong drug, or error identified was the deliberate violation of guidelines
wrong patient and the use of computerised labelling has when injecting bolus doses faster than the recommended
led to transposition and typing errors which are among time of 3–5 minutes. Causes of administration errors
the most common causes of dispensing error. included a lack of perceived risk, poor role models, and lack
of available technology. Mistakes tended to occur when
Approaches to reducing dispensing errors include: drug preparation or administration involved uncommon
procedures with causes including a lack of knowledge of
• Ensuring a safe dispensing procedure. the preparation or administration procedures and the
• Separating drugs with a similar name or appearance. complex design of equipment. In contrast a major error
• Keeping interruptions in the dispensing procedure to rate of 0·19% in 30,000 cytotoxic preparations has been
a minimum and maintaining the workload of the reported, suggesting that medication error rates may be
pharmacist at a safe and manageable level. lower in situations where intravenous drugs are
• Awareness of high risk drugs such as potassium administered in specialised units. Whilst this rate may be
chloride and cytotoxic agents. interpreted as being low, if such a rate were to be
• Introducing safe systematic procedures for dispensing extrapolated each year across a large clinical area, the
medicines in the pharmacy. numbers of patients affected would be significant.

ADMINISTRATION ERRORS Contributing factors to drug administration errors

include a failure to check the patient’s identity prior to
Administration errors occur when a discrepancy occurs administration and the storage of similar preparations in
between the drug received by the patient and the drug similar areas. Environmental factors such a noise,

J R Coll Physicians Edinb 2007; 37:343–346

© 2007 RCPE
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interruptions whilst undertaking a drug round, and poor The licensing process could also consider any differences
lighting may also contribute to these errors. The between the product used in clinical trials and that used
likelihood of error is also increased where more than one in clinical practice and the medication error potential of a
tablet is required to supply the correct dose or where a particular product should be formally assessed during the
calculation to determine the correct dose is undertaken. post-marketing surveillance process.
Approaches to reduce drug administration errors include:
CONCLUSIONS
• Checking the patient’s identity.
• Ensuring that dosage calculations are checked All healthcare professionals have a responsibility in
independently by another health care professional identifying contributing factors to medication errors and
before the drug is administered. to use that information to further reduce their
• Ensuring that the prescription, drug, and patient are in occurrence. A multidisciplinary approach to solving the
the same place in order that they may be checked problem of medication errors needs to be taken.
against one another. Significant increases in the reporting of medication errors
• Ensuring the medication is given at the correct time. have been noted where confidential, no-fault reporting has
• Minimising interruptions during drug rounds. been implemented. Creating a culture of safety does not
just mean eradicating the culture of blame but also involves
Clinical pharmacists are key to ensuring the safe use of changing the entire way one thinks about and approaches
medicines and the current system whereby wards are the work in the medication cycle. Whilst it may seem
visited daily by clinical pharmacists places them in a good counterintuitive to reward people for reporting failures,
position to recognise particular training needs that can be this is what is required in order to create a culture of
addressed. safety in order that one can understand what causes
medication errors and implement systems to prevent
Finally, an alternative approach to reducing medication them recurring. However, confidential, non-punitive
errors is to target high alert drugs and procedures. The reporting has its faults including the fact that the true
implementation of a carefully planned series of low-cost number of medication errors will still not be known and
interventions focused on high-risk medications, driven by that confidential reports may be difficult to validate. We
information derived largely from internal event reporting , must recognise that the current approaches to preventing
and designed to improve a hospital’s medication safety, have medication errors are inadequate and require a shift in
been shown to significantly reduce patient harm as a result emphasis to a scientific investigation of preventable patient
CME

of medication errors. Drugs which have been identified as harm. Medication use systems can be made safe by making
having a high potential for error include potassium chloride, them resistant to error and by adding important checks
high strength narcotics, cancer chemotherapy, heparin, and controls. Unfortunately the difficulties associated with
insulin,vasoactive drugs,and epidural infusions. Attempts to making systems failsafe explain the significant number of
reduce the harm caused by intravenous errors in the past medication errors that continue to occur.
have focused on restricting choice and removing the nurse KEYPOINTS
from the drug preparation step. Restricted supply of strong
potassium chloride to reduce medication errors has long • Medication errors are one of the most preventable
been recommended and only stocking one strength of causes of patient injury although the incidence of
morphine ampoule on paediatric wards has been successful such errors varies widely as a result of differing
in preventing errors involving selection of the incorrect definitions and methodologies.
ampoule. Design issues such as ampoules that look similar • The majority of medication errors occur as a result
and the complex design of infusion pumps have been of poor prescribing, emphasising the need to
recognised as risk factors for intravenous administration improve prescribing skills.
errors and puts the onus on manufacturers to supply • The problems, sources and methods of avoiding
products to a high safety standard. medication errors are multifactorial and
multidisciplinary.
It has been suggested that the pharmaceutical industry • A non-punitive approach should be adopted to
could apply a framework of human error theory at the improve the rate of reporting of medication errors,
product design stage and include consultations with allowing further investigation of these important
health care professionals who will be using their product. causes of preventable patient harm.

FURTHER READING • Ferner RE,Aronson JK. Clarification of terminology in medication

errors: definitions and classification. Drug Saf 2006;
• Barber N, Rawlins M, Dean Franklin B. Reducing prescribing 29(11):1011–22.
error: competence, control, and culture. Qual Saf Health Care • Flynn EA, Barker KN, Gibson JT, Pearson RE, Berger BA, Smith LA.
2003; 12(Suppl 1):i29–32. Impact of interruptions and distractions on dispensing errors in
• Dean B, Schachter M,Vincent C, Barber N. Causes of prescribing an ambulatory care pharmacy. Am J Health Syst Pharm 1999;
errors in hospital inpatients: a prospective study. Lancet 2002; 56(13):1319–25.
359(9315):1373–8. • Han WH, Maxwell SR. Are medical students adequately trained to
• Dean B, Schachter M,Vincent C, Barber N. Prescribing errors in prescribe at the point of graduation? Views of first year
hospital inpatients: their incidence and clinical significance. Qual foundation doctors. Scott Med J 2006; 51(4):27–32.
Saf Health Care 2002; 11(4):340–4.

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© 2007 RCPE