Medication Error

Contents
1. Definition
2. Causes of Medication Errors
3. Classification
4. NCC MERP Index
5. Common Error Hazards
6. Reporting Process
7. Strategies to Reduce Medication Errors
8. Safety Techniques
9. National Safety Efforts
10. Role of Pharmacist
 What is Medication Error?

The NCCMERP defines a medication error

as “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 health care professional,
patient or consumer.”

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review
for NAPLEX (Eighth edition.).
1
 Medication Error
Problem
1. The National Patient Safety Agency Report
2004 (UK) and the IOM Report 2000 (USA)
both highlighted that medical errors cause a
large number of deaths each year.
2. An estimated 44,000 to 98,000 deaths per
year are caused by medical errors. Of those
deaths, approximately 7000 are the result of
medication errors.
3. A call to action was given to improve patient
safety.

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review
for NAPLEX (Eighth edition.).
2
 Causes of Medication
errors
Medication errors may occur due to several reasons such as,
1. Overload at workplace
2. Shortage of staff
3. Lack of concentration
4. Lack of knowledge
5. No counter-check
6. Dangerous abbreviations
7. Verbal orders
8. Illegible prescription
9. Misinterpretation of prescription

3
Classification of Medication Errors

Medication errors may be classified according to

where they occur in the medication use cycle, i.e. at
the stage of prescribing, dispensing, or
administration of a drug.
1. Prescribing errors
2. Dispensing error
3. Administration error
Some other types also include;
4. Documentation error
5. Transcription error
6. Indent error

Williams, D. J. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37(4), 343. 4
 1. Prescribing Error
Prescribing errors may be defined as the incorrect drug
selection for a patient.
Such errors include;
1. Incorrect dose
2. Quantity of drug
3. Wrong indication
4. Lack of knowledge
5. Irrational combinations
6. Illegible handwriting
7. Inaccurate medication history
8. Drug allergies not identified
9. Inappropriate use of decimals
Williams, D. J. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37(4), 343. 5
Ratio of Prescribing Errors
In a four-week UK prospective study of 36,200
prescriptions,1·5% were found to have a prescribing
error, 25% of which were potentially serious. When
only serious errors were examined,58% of the
errors originated in the prescribing decision and
42% in medication order writing.
A recent research done in 2021 shows that out of
total medication errors there are 24% prescribing
errors and 4% of these result in injury to patients.

Williams, D. J. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37(4), 343

Osmani, F., Arab-Zozani, M., Shahali, Z., & Lotfi, F. (2023, May). Evaluation of the effectiveness of electronic
prescription in reducing medical and medical errors (systematic review study). In Annales Pharmaceutiques
Françaises (Vol. 81, No. 3, pp. 433-445). Elsevier Masson..
6
 Prescribing Errors

Illegible hand-writing Inappropriate use of

decimal
(Digoxin 0.5mg)

7
 2. Dispensing Error
Dispensing errors occur at any stage of the
dispensing process, from the receipt of the
prescription in the pharmacy to the supply of a
dispensed medicine to the patient.
Dispensing errors occur at a rate of 1–24 % and
include selection of the wrong strength or product.
Such errors include;
1. Wrong dose
2. Wrong drug
3. Wrong patient
4. LASA drugs
5. Failure to identify drug interactions

Williams, D. J. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37(4), 343. 8
 Ratio of Dispensing Errors

There is 98.3% accuracy in dispensing medication and

inaccuracy rate is 1.7%. Such as,
According to recent research done in 2023, the
worldwide prevalence of dispensing errors was 1.6%
across community, hospital and other pharmacy
settings.

Flynn E, et al. J Am Pharm Assoc. 2003;43:191–200

Um, I. S., Clough, A., & Tan, E. C. (2023). Dispensing error rates in pharmacy: A systematic review and meta- 9
analysis. Research in Social and Administrative Pharmacy..
 Examples of Dispensing Error
1. When drugs have similar names or appearance (LASA
drugs)
Lasix (frusemide) and Losec (omeprazole)
2. Drugs with similar names
Amiloride 5mg and Amlodipine 5mg

Williams, D. J. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37(4), 343. 10
 3. Administration Error
Administration errors occur when a discrepancy occurs
between the drug received by the patient and the drug
therapy intended by the prescriber.
Drug administration is associated with the “five rights”;
(giving the right dose of the right drug to the right patient at
the right time by the right route).
Such errors include;
1. Error of omission
2. Incorrect administration technique
3. Administration of incorrect and expired preparation
4. Lack of available technology
5. Lack of knowledge of preparation and administration
procedure
Williams, D. J. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37(4), 343. 11
 Ratio of Administration
Errors
Administration errors mostly occur in case of IV administration. A
recent study of intravenous drug administration suggested an error
rate of 50% in either the preparation of the drug or its
administration.
The most common type of error identified was the deliberate
violation of guidelines when injecting bolus doses faster than the
recommended time of 3–5 minutes.
According to the recent studies, prevalence of administration errors
among all medication errors is 13.7%.

Williams, D. J. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37(4), 343.

Jessurun, J. G., Hunfeld, N. G. M., de Roo, M., van Onzenoort, H. A. W., van Rosmalen, J., van Dijk, M., & van den Bemt, P. M. L. A.
(2023). Prevalence and determinants of medication administration errors in clinical wards: a two‐centre prospective observational 12
study. Journal of clinical nursing, 32(1-2), 208-220.
 Example of Administration
Error
The intravenous route of administration is a particularly
complex process during which errors frequently occur
and is associated with significant risk to patients as
some have died as a result of the administration of
cytotoxic drugs intrathecally instead of intravenously.
An other example is associated with omission error, as a
patient was supposed to receive digoxin 0.5mg orally in
the morning but did not receive the dose. Possible
cause may be that nurse was she forgot to administer
the dose.

Williams, D. J. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37(4), 343. 13
 Medication Error

Williams, D. J. (2007). Medication errors. Journal-Royal College of Physicians of Edinburgh, 37(4), 343. 14
 Common Error Hazards
1. Dangerous abbreviations
2. Confusing symbols and abbreviations
3. LASA drugs
4. High-risk drugs

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
15
 1. Dangerous Abbreviations
Many common abbreviations are associated with errors such
as,
1. U, IU: (units); Easily misinterpreted as a number (1, 2,4,6
etc)
2. QD, Q.D., qd, q.d.: (daily); These common abbreviations
have been misinterpreted as QID/qid (four times daily)
3. QOD, qod, Q.O.D: (every other day); ); These common
abbreviations have been misinterpreted as QID/qid (four
times daily) resulting in overdose.
4. Trailing zero; When a dose is ordered and followed with a
decimal point and a zero i.e. 2.0mg/25.0mg, the decimal
point may be missed resulting in overdose of drug.
5. Lack of Leading Zero; Sometimes if a dose is less than 1mg
written in a way (.25mg) without leading zero results in
Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
misunderstanding.
NAPLEX (Eighth edition.).
16
 2. Confusing Symbols and Abbreviations
There are many hazardous symbols and abbreviations that should
be used with caution when writing a prescription and examined
carefully when filling a prescription such as,
1. cc (cubic meter): misinterpreted as zero.
2. ug (microgram): misinterpreted as mg.
3. Symbols (</>): mistaken for each other.
4. HCT (hydrocortisone): misinterpreted as Hydrochlorothiazide.
5. HCl (hydrochloric acid): misinterpreted as KCl (potassium
chloride)

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
17
 3. LASA Drugs
Look-a-like or sound-a-like drugs also result in medication errors
such as,
1. Amitriptyline and Aminophylline
2. Cisplatin and Carboplatin
To avoid these errors Institute for Safe Medication Practices (ISMP)
offer several suggestions including the use of computerized
reminders, name alert stickers etc.

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
18
 4. High-Risk Drugs
Certain potent drugs have been implicated in many serious and
tragic medication errors. These drugs are called high-risk or
high-alert drugs. Examples include,
1. Blood-modifying agents (heparin, warfarin)
2. Narcotics and Sedatives
3. Neuromuscular paralyzing agents (succinylcholine,
vecuronium)
4. Chemotherapy Drugs

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
19
Reporting of Medication
Error
The ISMP National Medication Errors
Reporting Program (ISMP MERP) is an
internationally recognized program for
healthcare professionals to share potential or
actual medication errors that occurred at
their workplace. Reporting an error or
hazardous condition is simple and
confidential.

Cohen, M. R., & Smetzer, J. L. (2017). ISMP medication error report analysis. Hospital pharmacy, 52(6), 390-393.
20
 NCC MERP Medication Error Reporting
System
NCCMERP has developed a medication error taxonomy tool to
aid healthcare workers and organizations characterize, trace,
and analyze medication errors in a standardized, methodical
approach.
The taxonomy is useful for developing a medication error
database and designing an error reporting or data collection
form.
One key component of the taxonomy, which categorizes an error
in accordance with the severity of the outcome on a scale from
A to I, is the NCCMERP medication index. Factors such as
whether the error got to the patient and if the patient was
affected by the error and to what level, are considered by the
index.

Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., ... & Al-Omari, A. (2021). The
effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46. 21
NCC MERP Index for Categorizing Medication Errors

Devine, E. B., Hansen, R. N., Wilson-Norton, J. L., Lawless, N. M., Fisk, A. W., Blough, D. K., ... & Sullivan, S. D. (2010). The
impact of computerized provider order entry on medication errors in a multispecialty group practice. Journal of the American 22
Medical Informatics Association, 17(1), 78-84.
Strategies to Reduce Medication
Errors
1. Computerized Physician Order Entry (CPOE)
2. Barcode
3. Alerts about medication errors
4. Smart Infusion Pumps

Riaz, M. K., Riaz, M., & Latif, A. (2017). Medication errors and strategies for their prevention. Pakistan journal of
pharmaceutical sciences, 30(3). 23
 1. Computerized Physician Order
Entry (CPOE)
CPOE is a health information technology system that allows
healthcare providers to enter, modify, and manage orders for
medications, lab tests, imaging, and other treatments
electronically, rather than using traditional paper-based methods.
Benefits:
1. Reduction in medication errors
2. Enhanced patient safety
3. Improved efficiency
4. Easy access to patient data
5. Improved communication among HCP

Ciapponi, A., Nievas, S. E. F., Seijo, M., Rodríguez, M. B., Vietto, V., García-Perdomo, H. A., ... & Garcia-Elorrio, E. (2021).
Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews, (11).
24
 2. Barcode System

Barcode system refers to the use of barcode scanning at the

time of medication administration. Typically, both the
medication and the patient wristband are scanned to ensure
the right medication is being administered to the right patient.
Benefits:
1. Accurate identification
2. Reduction in medication errors
3. Improved patient safety
4. Streamlined work-flow

Zheng, W. Y., Lichtner, V., Van Dort, B. A., & Baysari, M. T. (2021). The impact of introducing automated dispensing cabinets,
barcode medication administration, and closed-loop electronic medication management systems on work processes and
safety of controlled medications in hospitals: A systematic review. Research in Social and Administrative Pharmacy, 17(5), 25
832-841.
 3. Alerts about Medication
Errors
Alerts about medication errors are critical notifications generated
by healthcare systems to help prevent potential adverse events
related to medication use. These alerts can arise from various
systems, including Computerized Physician Order Entry (CPOE),
Electronic Health Records (EHRs), and Medication Error Reporting
Systems (MERS).
Some alerts related to medication errors are:
1. Allergy alerts
2. Drug interaction alerts
3. Dosage alerts
4. Duplicate therapy alerts
5. Expiry alerts

Poon, E. G., et al. (2010). "Effect of Bar-Code Technology on the Safety of Medication Administration." New England Journal
of Medicine, 362(18), 1698-1707. doi:10.1056/NEJMsa0906957
26
 4. Smart Infusion Pumps

Smart infusion pumps are advanced medical devices designed to

deliver fluids, medications, and nutrients to patients in a controlled
and precise manner. They incorporate technology to enhance safety,
improve accuracy, and reduce the risk of medication errors.
Benefits:
1. Increased patient safety
2. Improved accuracy
3. Simple interface
4. Constant supervision

Kan, K., & Levine, W. C. (2021). Infusion Pumps. In Anesthesia equipment (pp. 351-367). WB Saunders . 27
 Safety Techniques in Community
Pharmacies
Several safety techniques are observed in community pharmacies
to prevent medication errors.
a. Keep work procedures organized and simplified.
b. Do not work on several prescriptions at once, just one at a
time.
c. Manage interruptions, do not be pressured to rush.
d. Smell check.
e. Bar code check.
f. Use a magnifying glass when needed.
g. Enhance the design of facility.

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
28
 National Safety Efforts
The safety efforts that are done to prevent the medication errors
include,
A. The Joint Commission’s current National Patient Safety Goals
for Accredited Organizations. These goals include,
1. Patient identification
2. Good communication
3. List of “do not use” abbreviations
4. Improve safe use of medicines
5. Reduce the risk of infections
6. Accurate patient record

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
29
B. The 5 Million Lives Campaign initiated by the Institute for HealthCare
Improvement.

1.Purpose:
“To protect patients from five million incidents of medical
harm over the next 2 years (December,2006 to
December,2008).”
2. Twelve interventions were identified. These interventions
include,
a. Preventing adverse drug events through medication
reconciliation.
b. Preventing surgical site infections by appropriate care
and antibiotic use.
c. Focusing on preventing harm from high-risk medications
such as anti-coagulants, sedatives, narcotics and insulin.
d. Reporting MRSA infections through appropriate evidence-
based practices.

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
30
C. The IOM in July 2006 released its report “Preventing Medication
Errors.” Several recommendations were made to improve patient safety
including,
1. Enhancing role of patients in medication
management
2. Improving patient education
3. Increasing the use of technology such as e-
prescribing

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
31
D. Medication Error Reporting

The reporting of medication errors provides critical

safety feedback. The ISMP Medication Error
Reporting Program (MERP) provides an outline,
confidential means of error reporting.
According to ISMP, inclusion of reporters identity
and location is optional. The information is shared
with the FDA’s MedWatch program as well as with
the manufacturer/labeler.

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
32
E. The Sorry Works Coalition

It is an organization of various individuals

(health-care professionals, lawyers etc.)
who promote the necessity of disclosure
and apology following error. The coalition
provides training and education programs.

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
33
F. The Institute of Safe Medication
Practices
This institute focuses its efforts on
medication errors prevention and patient
safety. The ISMP publishes four different
newsletters, provides consulting services,
and also presents various educational
programs, services, safety
recommendations and activities.

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
34
G. National Patient Safety Foundation
NPSF
This foundation represents stake-holders
from a broad array of disciplines,
including patients and families. The
NPSF mission is to focus on improving
patient safety. It provides numerous
resources, publications and activities for
improving patient’s safety.

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
35
H. Institute of Health Care Improvement
IHI
The Institute of Health Care
Improvement has created the IHI Open
School. Online modules regarding
patient safety and quality assurance are
available on it. Additional resources and
material is also provided on it.

Shargel, Leon, Alan H.Mutnick, Paul F. Souney, Larry N. Swanson. (2013). Comprehensive pharmacy review for
NAPLEX (Eighth edition.).
36
Role of Pharmacist in Reporting Medication Errors
Numerous studies have demonstrated positive outcomes and
a reduction of medication-related adverse events in patients
when medication therapy is managed by pharmacists.
Pharmacists play a vital role in reducing medication errors
through various strategies and practices.
1. Medication review and verification
2. Patient counseling and education
3. Therapy evaluation
4. Effective utilization of technology
5. Implementing risk management strategies

American Pharmacists Association (APhA). (2020). "Pharmacists' Role in Preventing Medication Errors."
37
Questions & answers
Thank You
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