From the Oath of Hippocrates, this means “First, Do No Harm” and reiterates the role of healthcare workers in preventing ADEs. Most MEs do not result in patient harm. If harm occurs, it can range from an extra day of monitoring in the hospital to permanent bodily damage or even death.
Medication errors that are most likely to cause harm to the patient include incorrect administration of medication (such as inappropriately crushing tablets), delivering drugs through the wrong route (such as IV vs intramuscular), and dispensing wrong medications. Insulin, morphine, and heparin are cited as being the agents most frequently involved in errors that result in harm to patients.20,21
Causes of Medication Errors
As shown in Fig. e4-1, medication selection and procurement is the first step in the medication process. MEs in this step include failing to order adequate stock of a medication to meet patient needs, ordering expired or adulterated medication, confusion with substitutions during product shortages and recalls, and ordering the incorrect product, strength, or dilution.
The second step is storage. An ME occurs when any medication that has been stored improperly is subsequently given to a patient. This could include failing to refrigerate a medication or failing to protect a medication from light.
The third step is ordering and transcribing. MEs in ordering occur when the drug selected and/or its dose, frequency, or dosing duration is not appropriate for the patient’s disease or physiologic condition. MEs in the transcribing phase include failure to correctly interpret the medication order.
During preparing and dispensing, health professionals must obtain and package the correct drug, dose, or dilution of a product. Medication dispensing errors are defined as any discrepancy between the medication dispensed and the original prescriber’s order.
Likewise, an ME in administration is any discrepancy between how the medication is given to the patient and the administration directions from the physician or hospital guidelines.
Medication errors involved in monitoring and evaluating the effects of medication are defined as not ensuring proper follow-up of the therapeutic effect of a medication or failing to recognize an adverse effect of a medication.
One analysis showed that the most common errors involved prescriptions in which a medication was incorrectly prescribed (18.5%), dosage or quantity was incorrectly interpreted during dispensing (25.5%), and omission (25.6%), in which the prescribed medication was not administered.21 Other studies have slightly different descriptions of the medication ordering process. Bates et al. found 49% of MEs occur during the ordering phase, 11% during the transcribing phase, 14% during the processing (preparing and dispensing) phase, and 26% in the administration phase.22 A majority of errors in the ordering phase are wrong dose or frequency, known drug allergy, and drug-drug interactions.23 Many errors occur in the administration phase, such as wrong dose or incorrect drug administration technique.23
Medication errors are preventable. ADEs are preventable if they result from an error. In one analysis, Leape et al. found two-thirds of ADEs to be preventable with an incidence of error caused by provider negligence at around 40%.24 This same study categorizes errors as diagnostic, treatment, preventive, or other. The key is in finding the appropriate system or process at the correct step in medication distribution in an attempt to completely alleviate the risk of error.
Medication errors occur for a number of reasons, including the following:
Ambiguous strength designation on labels or in packaging
Drug product nomenclature (look-alike or sound-alike names, use of lettered or numbered prefixes and suffixes in drug names)
Equipment failure or malfunction
Improper use of electronic order entry systems
Inaccurate dosage calculation
Inadequately trained personnel
Inappropriate abbreviations used in prescribing
Lapses in individual performance
Preventing Medication Errors
It is important to understand that it is human nature to make mistakes. Furthermore, medication-use systems are extremely complex. Therefore, it is vital to create systems with built-in safeguards in order to reduce risk and promote safe use of medications. Systems for ordering, dispensing, and administering medications should be designed to minimize or prevent error.
Errors can occur at any step in the medication-use process. For each type of error, it is important to determine the root cause, or main reason, for the error. After researching the error and determining its root cause, a tracking system for MEs should be created. Multiple examples of tracking systems are available; errors may be grouped by the type of error or the extent of patient harm.
To design safer medication delivery systems, data must be collected, analyzed, and trended. MEs can be classified by the type of technical error that occurred. The ASHP Guidelines on Preventing Medication Errors in Hospitals classifies errors as shown in Table e4-2. System failures teach health professionals a tremendous amount about the weaknesses inherent in today’s complex medical delivery processes. Once tracking systems are in place for MEs and ADEs, processes and systems can be put in place to prevent errors. This may require an upgrade to the current computer program, an upgrade to that software, or an entirely new system. It may mean separating look-alike, sound-alike medications. It may mean creating preprinted orders based on guidelines to prevent inappropriate drug, dose, or monitoring. Training of staff may be required, and monitoring and follow-up are often needed.
TABLE e4-2Types of Medication Errors |Favorite Table|Download (.pdf) TABLE e4-2 Types of Medication Errors
|Type of Errora ||Examples |
|Prescribing error ||Incorrect drug selection (based on indications, contraindications, known allergies, existing drug therapy, or other factors), dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a drug product ordered or authorized by physician (or other legitimate prescriber); illegible prescriptions or medication orders that lead to errors that reach the patient |
|Omission errorb ||Failure to administer an ordered dose to a patient before the next scheduled dose |
|Wrong time error ||Administration of medication outside a predefined time interval from its scheduled administration time (this interval should be established by each individual healthcare facility) |
|Unauthorized drug errorc ||Administration of medication not authorized by a legitimate prescriber for the patient |
|Improper dose errord ||Administration of a dose that is greater than or less than the amount ordered by the prescriber or administration of duplicate doses to the patient (ie, one or more dosage units in addition to those that were ordered) |
|Wrong dosage-form errore ||Administration of a drug product in a different dosage form than ordered by the prescriber |
|Wrong drug-preparation errorf ||Drug product incorrectly formulated or manipulated before administration |
|Wrong administration-technique errorg ||Inappropriate procedure or improper technique in the administration of a drug |
|Deteriorated drug errorh ||Administration of a drug that has expired or for which the physical or 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 |
|Adherence error ||Inappropriate patient behavior regarding adherence to a prescribed medication regimen |
|Other medication error ||Any medication error that does not fall into one of above redefined categories |
Implementation strategies to reduce MEs:
Computerized provider order entry (CPOE)
Automated drug-distribution cabinets enabled with bar-code scanning
Robotic drug dispensing systems (intravenous and oral products)
Bar-code-assisted medication administration (BCMA)
Smart IV infusion pumps with a two-way interface to an electronic medical record (EMR)
Studies have shown many MEs and ADEs are preventable. Numerous studies have shown roughly 25% of all MEs and ADEs would never have occurred if various strategies had been implemented. CPOE has been shown to reduce preventable ADEs by 17% and decrease nonintercepted serious MEs by 50%.25
Other strategies, such as automated drug-distribution cabinets enabled with bar-code scanning, help to decrease storage and dispensing errors. This strategy, however, is not without its own potential for error as pharmacy technicians and others, such as nurses and pharmacists, must use the bar-code scanner when filling the cabinets and removing medications to assure for the safety double check.
The use of BCMA is growing in popularity with many health systems already implementing this technology. When used appropriately, BCMA can decrease MEs by 65% to 86%.26,27 BCMA has also been shown to prevent medication administration errors in outpatient areas—most notably the emergency department where BCMA is not routinely used.28 The BCMA process involves using medications dispensed by the pharmacy with a bar code on the medication. This bar code is on all medications regardless of route including IV medications. If the incorrect medication is scanned, a warning will appear. As with other strategies, there is potential for error with bar-code administration as well. Examples would include nurses who override the warnings or who administer the medication before scanning the bar code. Both of these instances could lead to either an ME or ADE or both.
Most IV products are delivered to patients using “smart pumps.” These pumps allow the organization to program the pump with standard concentrations and standard infusion ranges, preventing the nurse from administering it outside specified limits for each drug. These pumps are also set up with soft and hard stops whereby if a nurse sets the pump outside specified ranges, the pump could alarm with a soft stop in which case the nurse could override it, or a hard stop in which case the nurse would be unable to override the alarm. The Institute for Safe Medication Practices cautions that while this technology can reduce MEs and ADEs, “smart pumps aren’t smart by themselves.” The information on most smart pumps cannot be viewed on the EMR as pump software is not owned by most EMR vendors. The next step to “close the loop” in preventing intravenous infusion errors is to integrate smart pumps with the EMR so that data are sent bidirectionally between the two technologies.
A new approach to preventing MEs is to use computer simulation technology to educate and train healthcare workers in preventing errors. Organizations have been using simulation to establish competency in a variety of areas, such as airway management, surgical procedures, and basic life support. A recent review of the literature noted a growing interest in establishing programs that simulate potential for MEs.29 When properly designed, simulations may assist providers in preventing serious and fatal MEs by providing “real life” experience.
It is important to remember the significance of MEs and ADEs on patients and the healthcare system. The cost of improving systems and training is negligible compared with the value of lives saved. In addition, the introduction of technology brings on new errors; the hope is that these errors will cause less harm than historical dispensing errors. Healthcare workers must always be diligent in predicting new sources of error from any robotic or automated system.