Here is a comprehensive Training Material on Medication Errors and Adverse Drug Reactions
(ADRs), designed according to NABH guidelines, suitable for use in hospitals, nursing colleges, or
pharmacovigilance training programs.
Training Module: Medication Errors and Adverse Drug Reactions
Objective of Training
By the end of this session, participants will be able to:
• Define and identify medication errors (MEs) and adverse drug reactions (ADRs)
• Understand types, causes, and consequences of MEs and ADRs
• Know how to report and prevent MEs and ADRs
• Comply with NABH and PvPI standards for patient safety
Section 1: Definitions
Medication Error (ME)
A preventable event that may cause or lead to inappropriate medication use or harm to a patient
while the medication is in the control of the healthcare professional, patient, or consumer.
Source: NCC MERP
Examples:
• Wrong patient
• Wrong drug or dose
• Omission of dose
• Inappropriate administration time
Adverse Drug Reaction (ADR)
A harmful or unintended reaction to a drug at normal doses used in humans for prevention,
diagnosis, or treatment.
Source: WHO
Examples:
• Allergic rash from penicillin
• Liver damage from anti-TB drugs
• Hypoglycemia from insulin
Section 2: Types
Types of Medication Errors
Type Example
Prescribing Illegible handwriting, wrong dose
Dispensing Wrong drug given from pharmacy
Administration Wrong route/time/patient
Monitoring Not adjusting dose after lab results
Types of ADRs (by WHO classification)
Type Description
Type A Predictable and dose-related (e.g. bleeding with warfarin)
Type B Unpredictable (e.g. allergy to penicillin)
Type C Long-term use (e.g. adrenal suppression by steroids)
Type D Delayed (e.g. carcinogenic effect)
Type E Withdrawal effects (e.g. opioid withdrawal)
Section 3: Causes & Risk Factors
Causes of Medication Errors
• Look-alike/sound-alike (LASA) drugs
• Poor communication
• Use of unsafe abbreviations
• Inadequate training or workload stress
• Absence of double-checking
Risk Factors for ADRs
• Polypharmacy
• Renal/hepatic impairment
• Pediatric or geriatric age groups
• Previous allergic reactions
• Genetic factors
Section 4: Reporting Process
How to Report a Medication Error (ME)
1. Inform the supervisor/doctor immediately
2. Stabilize the patient
3. Fill the Medication Error Reporting Form
4. Submit to Quality/Risk Management Department
5. Participate in Root Cause Analysis (RCA) if required
How to Report an ADR
1. Identify and record the suspected ADR
2. Use the ADR Reporting Form (PvPI yellow form)
3. Submit to the Pharmacovigilance Committee
4. Forms are sent to AMC (Adverse Drug Reaction Monitoring Centre) or PvPI
Section 5: Prevention Strategies
Best Practices for Preventing Medication Errors
• Use Five Rights: Right patient, drug, dose, route, time
• Avoid dangerous abbreviations (e.g. IU, U, QD)
• Implement LASA drug policies
• Use electronic prescribing (if available)
• Encourage non-punitive reporting
Preventing ADRs
• Take complete drug and allergy history
• Monitor therapeutic drug levels
• Educate patients about side effects
• Adjust doses for renal/hepatic impairment
Section 6: NABH and PvPI Compliance
NABH Guidelines
• Medication safety must be ensured across the continuum of care
• Standard COP.13: The hospital should have a defined system for safe medication
management
• MEs and ADRs must be documented, analyzed, and used for improvement
• Regular staff training is mandatory
🇮🇳 Pharmacovigilance Programme of India (PvPI)
• National program by IPC, Ghaziabad
• Collects data on ADRs
• Hospitals are encouraged to report ADRs regularly
• ADR reports are sent to WHO Uppsala Centre
Interactive Activity (Optional)
Case Study:
A nurse accidentally administers 10 mg morphine instead of 1 mg due to decimal point misreading.
• What type of error is this?
• What steps should be taken?
• How will you report and prevent it?
Assessment Quiz (Sample Questions)
1. What are the "Five Rights" of medication administration?
2. Give two examples of Type A and Type B ADRs.
3. Name two tools to prevent LASA errors.
4. What is the purpose of PvPI?
Training Checklist
Activity Completed ( )
Presentation delivered
Reporting forms distributed
Case study discussed
Quiz conducted
Feedback collected
Attachments
• Medication Error Reporting Form
• ADR Reporting Form (PvPI)
• NABH Medication Safety Policy (Template)
• Root Cause Analysis (RCA) Format
Would you like:
• A PowerPoint presentation version?
• A PDF handout for printing?
• Translated version in Hindi or local language?
Let me know and I can generate it for you!
