SHRI GURU RAM RAI INSTITUTE OF TECHNOLOGY AND SCIENCE

MEDICATION ERRORS

Patients depend on health systems and health professionals to help them stay healthy. As a
result, frequently patients receive drug therapy with the belief that these medications will help
them lead a more healthy life. But there are many drug related challenges at various levels,
involving prescriber, pharmacists and patients. Errors in medication use process, including
errors in medication prescribing, dispensing, administering and monitoring are responsible
for a significant number of drug-related deaths. While medication misadventure can occur
anywhere in the health care system from prescriber to dispenser to administration and finally
to patient use, the simple truth is that many errors are preventable, and pharmacists assume
active role in appropriate use of drugs.

What is a medication error?

A medication error is any error in the medication process, whether there are adverse
consequences or not. Most errors occur during the administration stage followed by
prescription, preparation, and transcription. Nurses and pharmacists intercept up to 70% of
prescription errors. Preparation errors occur when there is a difference between the ordered
amount or concentration of a medication and what is actually prepared and administered. The
industry standard for pharmaceutical preparations is a concentration difference of less than
10%. However, approximately two thirds of infusion prepared by nurses are outside industry-
accepted standards and 6% contain a greater than two fold concentration error. Transcription
errors are usually attributed to handwriting, abbreviation use, unit misinterpretation (‘mg’ for
‘mcg’), and mistakes in reading.

Definition:
An error is “A failure to perform an intended action that was appropriate under the given
circumstances”. Medication errors is defined as “Any preventable event that may cause or
lead to an inappropriate medication use or patient harm while in the control of the health care
professional, patient or consumer.

The American National Coordinating Council for Medication Error Reporting and Prevention
(NCC MERP) define: “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
healthcare professional, patient, or consumer. Such events may be related to professional,
patient, or consumer. Such events may be related to professional practice, healthcare

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products, procedures and systems including prescribing, order communication, product

labeling, packaging, nomenclature, compounding, dispensing, distribution, administration,
education, monitoring and use”.

A medication error can also be broadly defined as “A dose of medication that deviates from
physian’s order as written in the patient’s chart or from standard hospital policy and
procedures”

Classification:
The most common way to classify errors is to identify them by type. American Society for
Hospital defines different categories of medication errors based on the type of error.

Fig: Types of Medication Errors

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Table 1. Types of Medication Errors

Prescribing error Prescribing error 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
Omission error The failure to administer an ordered dose to a patient before the next
scheduled dose, if any.
Wrong time error Administration of medication outside a predefined time interval from
its scheduled administration time (this interval should be established
by each individual health care facility).
Unauthorized drug Administration of the patient of medication not authorized by a
error legitimate prescriber for the patient.
Improper dose error Administration to the patient of a dose that is greater than or less than
the amount ordered by the prescriber or administration of duplicate
doses to the patient, i.e., one or more dosage units in addition to those
that were ordered.
Wrong dosage-form Administration to the patient of a drug products in a different dosage
error form than ordered by the prescriber
Wrong drug – Drug product incorrectly formulated or manipulated before
prescription error administration.
Wrong In appropriate procedure or improper technique in the administration
administration- of a drug.
technique error
Deteriorated drug Administration of a drug that has expired or for which the physical or
error chemical dosage-form integrity has been compromised.
Monitoring error Failure to review a prescribed regimen for appropriateness and
detection of problems, or failure to use appropriate clinical or
laboratory data for adequate assessment of patient response to
prescribed therapy.
Compliance error Compliance errors occur when patients use medications
inappropriately.

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Causes for medication errors:

The majority of medication errors do not occur in emergency situations but while performing
routine clinical tasks. The source of these errors can lie at any stage of the process from the
initial prescription of medication to its administration.
 Incomplete patient information (not knowing about patients’ allergies, other
medicines they are taking , previous diagnoses, and lab results)
 Unavailable drug information (such as lack of up-to date warnings)
 Inexperienced or inadequately trained staff
 Miscommunication of drugs orders, which can involve poor handwriting , confusion
between drugs with similar names, misuse of zeros and decimal points, confusion of
metric and other dosing units, and inappropriate abbreviations.
 Factors such as similar product name or packaging from pharmaceutical companies.
 Lack of appropriate labeling as a drug is prepared and repackaged into smaller units
 Environmental factors, such as lighting, heat, noise, and interruptions that can distract
health professionals from their medical tasks. Workplace environmental problems
increasing
 the job stress
 Excessive task demand leads to high work overload for staff.
 Work shift-more errors occur during the night
 Lack of patient couseling cause lack of patients’ understanding of their therapy
 Too many telephone calls
 Too many customers
 Lack of concentration
 Staff shortage
 Misinterpreted prescription
 Poor drug distribution practices.
 Access to drugs by non-pharmacy personnel
 Dose miscalculations

Medication error reporting system:

Intensive Monitoring System- If refers to a continuous detection of medication error
in hospital via prescription auditing. Intensive monitoring system focuses on
prescription auditing as prescription is the first step in the treatment of patient.

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Intensive monitoring system is the best because it is always better to detect the error
at the very basic step before it reaches to the patient.
Spontaneous Reporting System- It means that it is the responsibility of each clinical
staff to inform the concern department immediately after any adverse drug reaction or
any kind of medication error.

Medication 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. By giving education about
medication, patients can act as the final check in the system. When patients take an active and
informed role in his or her health care, many errors can be prevented. Examples of
instructions to patients that can help prevent medication errors are:
 Know the names and indications of your medications
 Read the medication information sheet provided by your pharmacists
 Do not share your medications
 Check the expiration date of your medications and dispose of expired drugs
 Learn about proper drug storage
 Keep medication out of the reach of children
 Learn about potential drug interactions and warnings
 Prior Authorization
Prior authorization programs are used by managed health care systems as a tool to assist in
providing quality, cost-effective prescription drug benefits. Improving patient safety by
promoting appropriate drug use is an integral function of prior authorization programs.
Medication errors can be reduced by prior authorization systems in various ways. Prior
authorization may be used to protect against adverse events in highly contraindicated
populations.
Example: A prior authorization program employed to ensure that patients do not
receive certain drugs, such as antibiotics, for exceedingly long durations that could
put patients at increased risk for adverse events.
 Bar Code, bedside care systems:
Electronic technology is one of the way of improving patient safety and reduce medication

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Errors, through the use of standard machine-readable codes ("bar codes"). Medication bar
coding is a tool that can help ensure that the right medication and the right dose are
administered to the right patient. Bar code systems are particularly suited for efficient and
accurate checking functions that occurs when medication are dispensed and administered
could be done more efficiently and accurately if aided by bar code scanning. This application
would include having bar codes on the package of each medication dispensed and
administered, on a patient identifier and on the person dispensing and administering the dose.
Bar code system can be linked to clinical information and medication profile, so that when
the dose is dispensed and administered to a patient, an automatic check could be made to
ensure that the drug was prescribed for correct patient, the dose, time and route of
administration is correct, and that the patient does not have an allergy to the medication being
dispensed and administered. Moreover performance measurement system eg: late doses and
omitted could automatically be tracked, reducing the dependence on voluntary reporting or
observational based studies.
 Electronic Prescription Record:
An electronic prescription record (EPR) contains all the data legally required to fill, label,
dispense and/or submit a payment request for a prescription. Pharmacists use the record as a
tool to reduce medication errors by guarding against drug interactions, duplicate therapy and
drug contraindications. The EPR can also help reduce medication errors by helping
pharmacists monitor and audit utilization and by facilitating communication between health
care providers to improve patient care.
 E-prescribing
This is a computer application that utilizes electronic prescribing by entering orders on a
computer, known as Computerized Physician Order Entry (CPOE), is a technology that
could help prevent many medication errors. CPOE systems allow physicians to enter
prescription orders into a computer or other device directly, thus eliminating or significantly
reducing the need for handwritten orders. E-prescribing and CPOE can reduce medication
errors by eliminating illegible and poorly handwritten prescriptions, ensuring proper
terminology and abbreviations, and omitted information. More advanced CPOE software
incorporates additional safety features that allow the physician to have access to accurate
patient information, including patient demographic information such as age, medication
history and medication allergies.

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Electronic DUR
Pharmacists are able to conduct prospective online drug utilization reviews (DUR) due to the
technology of the electronic prescription record. The online DUR process allows the
Pharmacist to conduct a review of the prescription order at the time of filling. This
technology allows the pharmacist to assess the prescription order at the time of dispensing
and, using information from the patient’s medical and/or pharmacy record, determine the
appropriateness of the prescribed medication therapy. Medication safety issues commonly
addressed in an online DUR process include the following:
 Drug-disease contraindications
 Drug-drug interactions
 Incorrect drug dosage
 Inappropriate duration of drug treatment
 Drug-allergy interactions
 Clinical abuse or misuse
Automated Medication Dispensing
Automated medication dispensing systems are now widely used as a less labor-intensive
method of dispensing medications. Automated pharmacy dispensing systems are more
efficient at performing pharmacists’ tasks that require tedious, repetitive motions, high
concentration and reliable record keeping, which can all lead to medication dispensing errors.
When utilized appropriately, automated medication dispensing systems help to reduce
medication errors and improve patient safety. Many automated dispensing systems utilize the
bar coding technology.
Conclusion:
Medication errors are part and a serious problem in the health care system. Recognition of the
problem is one of the important step to minimize the occurrence of medication errors.
Pharmacist has responsibility of ensuring the safe and effective use of medications by
minimizing the medication errors. They must take the lead role in the medication use process.
Pharmacist need to contribute in improving patient care by actively participating and
pursuing improvements in the medication use process. Thus pharmacists and other health
care professionals involved in the medication use process must work together to develop a
systems approach to reduce medication error.

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Reference:

1. Academy of Managed Care Pharmacy, The Academy of Managed Care Pharmacy’s

Concepts in Managed Care Pharmacy, Medication error,
http://www.amcp.org/WorkArea/DownloadAsset.aspx?id=9300. (accessed on 22 May
2016)
2. Bonnie J et al. Development & validation of medication administration error
reporting survey. Advances in Patient Safety: From Research to Implementation,
2005: 4; 457-476.
3. Moyen E et al. Review Clinical review: Medication errors in critical care. Critical
Care, 2008: 12(2); 1-7
4. http://www.nccmerp.org/sites/default/files/fifteen_year_report.pdf/22 (accessed on
22 may 2016)
5. Parthasarathi G et al. A textbook of Clinical Pharmacy Practice, Second edition.
Universities Press, 2012, chapter 28, Medication errors and adverse drug events:486-
501.
6. Sudheer K D et al. Fundamentals of clinical pharmacy practice. PharmaMed Press,
2010, chapter 13, Medication errors: 233-247.
7. Roy V et al. Medication errors: causes & prevention. Health Administrator, 19(1); 60-
64.

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