Medication Errors

What is ME

• "A medication error is 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 labelling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

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How Do they Occur ?

• 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 and lack of patient education.

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At Prescribing Level :

• illegible handwritten prescriptions.• insufficient or missing information about co-prescribed medications,

past dose-response relationships, laboratory values and allergic sensitivities.

• Incorrect drug or dose is selection, 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.

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At Dispensing Level :

• 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 (e.g. dispensing the wrong drug, wrong dose or an incorrect entry into the computer system) and those of omission (e.g. failure to counsel the patient, screen for interactions or ambiguous language on a label).

The three most common dispensing errors are:

• Dispensing an incorrect medication, dosage strength or dosage form;

• miscalculating a dose

• and failing to identify drug interactions or contraindications

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At Administration Level :• Errors caused by drug administration can be made by the health

care provider or by the patient themselves.• Much of the problem in drug administration is communication.• Patients are often unaware that errors can happen and often do not

take an active role in understanding what is being communicated to them. Errors most often occur when communication is unclear regarding:

• Drug name, Drug appearance, why the patient is taking the drug, how much and how often to take it, when is the best time to take it, how long to take it, what common side effects could occur, what to do about a missed dose, common interactions with other drugs or foods, and whether this new drug replaces or augments other therapy.

• Over-the-counter medications can lead to medication errors because labels may not be sufficiently read or understood, and health care providers are often unaware when patients are taking over-the-counter medications

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Medication Error Evaluation and Assessment

Levels of Medication Errors

Prescribing error Administration error Dispensing error

Drug Use Without Indication Omission Error Wrong Drug

Incorrect Drug Selection Wrong Time Wrong Strength

Alternate Dosage form Wrong Frequency

Improper Dose Wrong Administration

Wrong Duration Wrong Dose

Wrong Frequency Compliance Error

Unauthorized Drug

Illegible Prescription

Drug / Class Duplication

Monitoring Error

Allergy

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Outcome categorization of ME

NO ERROR Category A

ERROR, NO HARM Category B Category C Category D

ERROR, HARM Category E Category F Category G Category H

ERROR, DEATH Category I

Category A: Circumstances or events that have the capacity to cause error; Category B:An error occurred but the

error did not reach the patient; Category C: An error occurred that reached the patient, but did not cause patient

harm; Category D:An error occurred that reached the patient and required monitoring to confirm that it resulted

in no harm to the patient and/or required intervention to preclude harm; Category E:An error occurred that may

have contributed to or resulted in temporary harm to the patient and required intervention; Category F:An error

occurred that may have contributed to or resulted in temporary harm to the patient and required initial or

prolonged hospitalization; Category G: An error occurred that may have contributed to or resulted in permanent

patient harm; Category H:An error occurred that required intervention necessary to sustain Life; Category I: An

error occurred that may have contributed to or resulted in the patient’s death.

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Cause(s) of medication error

Types of error Causes

Drug use without indication Lack of knowledge

regular practice

Incorrect drug selection Lack of knowledge

regular practice

contraindication (drug drug interaction)

Alternate dosage form regular practice

Improper dose Lack of knowledge

regular practice

contraindication (drug drug interaction)

Wrong duration Lack of knowledge

lack of intervention from pharmacist

Lack of follow-up by doctors

Wrong frequency Lack of attention by nurse

Prescribing error

No Instruction for use of Drug Lack of doctor’s time

Nursing work over load

Lack of attention by Clinical pharmacist.

Unauthorized drug Lack of attention by nurse

Illegible prescription Lack of doctor’s time

Drug / Class duplication Lack of knowledge of brands

Lack of doctor’s time

Monitoring error Lack of equipment

Cost

Lack of doctor’s time

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Keys to Error Prevention

• Patient Education

• Drug Utilization Evaluation Studies

• Proper Documentation of Medical Records

• Prescribing with Generic Names

• Electronic Technology (Bar coding, Electronic Prescription Monitoring)

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