Medication Errors


Article Author:
Rayhan Tariq


Article Editor:
Yevgeniya Scherbak


Editors In Chief:
Michelle Miranda


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/28/2019 11:57:14 PM

Introduction

Close to 6,800 prescription medications and countless over-the-counter drugs are available in the United States. To further complicate a practitioner's responsibility during patient care, there are thousands of health supplements, herbs, potions, and lotions used by the public regularly to treat their health problems. With the number of substances on the market, it is conceivable that mistakes can be made when practitioners prescribe or dispense drugs. Added to this is the high risk of interaction between substances. 

Each year, in the United States alone, 7,000 to 9,000 people die as a result of a medication error. Additionally, hundreds of thousands of other patients experience but often do not report an adverse reaction or other complication related to a medication. The total cost of looking after patients with medication-associated errors exceeds $40 billion each year. In addition to the monetary cost, patients experience psychological and physical pain and suffering as a result of medication errors. Finally, a major consequence of medication errors is that it leads to decreased patients satisfaction and a growing lack of trust in the healthcare system. [1][2]

Function

Medication errors can occur at many steps in patient care, from the point of ordering the medication to the time when the patient is administered the drug. In general, medication errors usually, occur at one of these points:

  • Ordering/Prescribing
  • Documenting
  • Transcribing
  • Dispensing
  • Administering
  • Monitoring

Medication errors are most common at the ordering or prescribing stage. Typical errors include the healthcare provider writing the wrong medication, wrong route or dose, or the wrong frequency. These ordering errors account for almost 50% of medication errors. Data show that nurses and pharmacists identify anywhere from 30% to 70% of medication-ordering errors. It is obvious that medication errors are a pervasive problem, but in the majority of cases, the problem is preventable. [3]

Issues of Concern

Types of Medication Errors

  • Prescribing
  • Omission
  • Wrong time
  • Unauthorized drug
  • Improper dose
  • Wrong dose prescription/wrong dose preparation
  • Administration errors including the incorrect route of administration, giving the drug to the wrong patient, extra dose or wrong rate
  • Monitoring error such as failing to take into account patient liver and renal function, failing to document allergy or potential for drug interaction
  • Compliance error such as not following protocol or rules established for dispensing and prescribing medications

Clinical Significance

Causes of Medication Errors

Distractions

One of the major causes for medication errors is a distraction. Nearly 75% of medication errors have been attributed to this cause. Physicians have many duties in a hospital (e.g., examining patients, ordering laboratory and imaging studies, speaking to consultants, rounding on their patients, speaking to patient family members, conversing with insurance carriers before ordering studies), and in the midst of all this they are often asked to write drug orders and prescriptions. In the hurry to be done with the duty of writing drug orders, sometimes a lapse of judgment develops and a medication error occurs. It can happen to the best physician. Sometimes the physician may be on the phone and a clinician may be standing with the order chart next to him or her asking for a drug order. Quicky,  the physician may scribble in a drug order, not paying attention to the dose or frequency. It is the unscheduled events in the life of a healthcare provider such as the constant pages, attendance at meetings, and answering telephone calls that disrupt patient care. Many physicians do not acknowledge that these distractions are a problem, but in reality, these distractions are often the cause of medication errors. [4]

To minimize distractions, hospitals have introduced measures to reduce medication errors. Most hospitals are working on ways to decrease distractions to ensure that medications orders do not occur. For example, physicians are urged to order drugs at a set time after rounding on their patients; this is a time when they also write their daily progress notes. Other clinicians are requested not to disturb the physician at this time of the day. In addition, clinicians are asked only to disrupt the physician for an emergency. In addition, physicians are being urged to develop a structure for their patient care that is organized so that distractions are limited. While answering a page is often necessary, many hospitals recommend that physicians not answer patient calls until patient duties are completed. In addition, healthcare institutions are now penalizing physicians who continue to have too many medication errors because of distractions; the end result is a restriction in prescribing privileges.

Of course, not all distractions can be eliminated because the practice of medicine is itself unpredictable and chaotic at the best of times.

Distortions

A very common cause of medication errors is distortions. The majority of distortions may originate from poor writing, misunderstood symbols, use of abbreviations, or improper translation. A significant number of healthcare providers in the United States are from foreign countries and often write orders for medications that are not even available domestically. When a practitioner questions the drug, the physician often asks the nurse or pharmacist to substitute the medication prescribed for a similar drug. This type of distortion can lead to major errors because neither the non-prescribing practitioner nor the pharmacist can substitute a drug. All hospital pharmacies have a list of medications available in the formulary and doctors should know what is available and limit the ordering from this list.

Illegible writing

Illegible writing has plagued both nurses and pharmacists for decades. Physicians are often in a hurry and frequently scribble down orders that are not legible; this often results in major medication mistakes. Taking shortcuts in writing drug orders is a prescription for a lawsuit. Often the practitioner or the pharmacist is not able to read the order and makes their best guess. If the drug required is a dire emergency, this also adds more risk to the patient. To eliminate such errors, most hospitals have rules that practitioners and pharmacists have to follow; if the drug order is illegible, the physician must be called and asked to rewrite the order clearly. The practitioner or the pharmacist should never take a guess at what the drug/dose is. The bad writing by physicians has become such a major problem, that the Institute of Safe Medication Practices has recommended complete elimination of handwritten orders and prescription. This problem has been resolved with the use of electronic records where everything is typed, and poor writing is no longer an issue; however, errors still can occur from writing the wrong drug, dose, or frequency. [5][6]

Approach every prescription with caution. In the last decade, there have been many new drug releases, and generics with similar names have flooded the market. In addition to having similar names, many of these medications have multiple uses and alternative names. If the diagnosis is not stated on the prescription, there is a risk that the drug may be prescribed for too long or an inadequate amount of time. With dozens of new generics with similar names, the risk of error is very high. To counter the consequences of unintended substitutions for medications, the US Pharmacopeia has listed the names of look-alike medications, and the ISMP has developed a list of abbreviations that are routinely misinterpreted. [5] 

Write down the precise dosage. Distortion of dose can easily occur when nonspecific abbreviations or decimal points are used without thought. One abbreviation that is often the cause of medication errors is the "Ug" symbol for micrograms. It is often mistaken for units and should be avoided at all costs. It is best to spell out the quantity.

Use metric measures: The use of apothecary measures are now part of the historical archives; weight measures like grains, drams, and minims have little meaning to the modern day healthcare workers and should no longer be used. Instead, use the universal metric measures that are preferred by pharmacists and practitioners. When using metric measures, be careful when and where you use the decimal point. For example, when writing dexamethasone 2.0 mg, if the decimal point is not visualized, then the nurse or the pharmacist may think it is 20 mg. On the other hand, a zero should always precede a decimal point. For example, when writing digoxin, it should be written as 0.25 mg and not just .25 mg. Again, if the decimal point is not seen, it can easily lead to a tenfold increase in dose.

Consider patient age: The two populations that are very sensitive to medications are the elderly and children. Always check the patient’s age and body weight to ensure that the dose administered is correct. In addition, if you write a prescription, write the age and weight of the patient on it so that the pharmacist understands how you derived the dose. In children, most drugs are prescribed based on body weight.

Liver and kidney function: Another very common reason for medication errors is not taking into account renal or liver failure. Patients with renal and liver dysfunction need lower doses. Otherwise, toxicity can result because of the failure to excrete or break down the medication.

Provide directions: Healthcare workers who write drug orders and prescriptions should never assume that the other party knows what you mean. Provide clear instruction on doses, the number of pills, and how and when the medication is to be taken. Writing orders like "take as directed" is a recipe for disaster. Similarly, "PRN" without an indication should never be used. It is an error in the making. Write down when the drug is to be taken and for what purpose (e.g., take 2 mg of morphine by mouth for pain. Take the morphine every 3 to 4 hours as needed for pain). Reducing medication errors requires open communication with the patient and the pharmacist ([7].

Use of Abbreviations: One very common cause of medication errors is the use of abbreviations. Often the the route of administration is abbreviated using suffix like QD, OS, TID, QID, PR, etc. QD (meaning once a day) can easily be mistaken for QID (four times a day). Additionally, these abbreviations can have several other meanings and can be misinterpreted. It is recommended that abbreviations not be used at all when writing medication orders. [8]

Duration of treatment: In the past, some physicians would simply write down the total number of pills that a patient is supposed to get without specifying the duration of treatment. It is vital to specify the duration of treatment and that the duration of treatment matches the number of pills prescribed. In addition, when writing about the quantity of the drug, it important to write down the actual number of pills (e.g., 90) rather than stating dispense for 2 months. Another reason for specifying the number of doses is that it requires the patient to comply with follow up and prevents them from just collecting older medications. If the patient has a chronic disorder, the practitioner should be treating each flare-up as a single event with a finite number of pills. If the patient has a flare-up or exacerbation, tell him or her to come to the clinic for an exam and at that time determine if more pills are needed. Just empirically prescribing pills for a theoretical recurrence only leads to confusion and a high risk of adverse reactions.

Remain alert for high-risk medications. For example, if a patient has a deep vein thrombosis or a prosthetic heart valve and requires warfarin, only prescribe for 4 weeks at a time and reassess the patient on each visit. Do not give warfarin for many months at a time. The patient needs to be monitored for the INR, and the dose may have to be adjusted.[9]

Always specify the indication for the drug. Writing the indication for the drug is highly recommended because many drugs have multiple uses. Unfortunately, the majority of prescriptions never have the diagnosis written and omitting this information increases the potential for complications. By writing the diagnosis, informs the pharmacist of the diagnosis and reminds the patient of the medication's purpose. This small step can facilitate counseling by the pharmacist, reinforce the patient's treatment plan, and provide ample opportunities for patient education. It also helps improve communication between the healthcare provider and the pharmacist. For example, corticosteroids, and anticonvulsants have many uses and it is important for the pharmacist to know what condition is being treated. [10] An anticonvulsant may be used to treat a migraine, neuropathic pain, or behavior, besides seizures.

Choose the appropriate drug for the patient population: When dealing with elderly patients, healthcare providers should avoid ordering drugs listed on the Beers criteria- this list of drugs is known to have the potential to cause adverse reactions in elderly individuals. [11]

Add supplemental instructions. Always add extra precautions when necessary. For example, when prescribing tetracyclines, the patient should be warned about sun exposure, or when taking ibuprofen, the patient should be told to take the medication with food. When prescribing metronidazole, warn the patient about alcohol use. Do not assume that the pharmacist will add these extra warnings when dispensing the drugs. For patients who cannot read or understand the instructions for prescribed medications, educate the family and provide verbal counseling when required.

Adopt a reporting system. The only way to reduce medication errors is to develop a reporting system and then make changes to prevent similar errors from reoccurring. Even a near miss should be reported. The staff should be encouraged to report without any repercussions. It is a great learning experience and enhances safety.

Discuss the patient's preferences. Considering the many drugs available to treat the same disorder, involve the patient in the decision making. The patient should be told about the potential adverse effects and cautions.

Write your contact number. Many healthcare providers write prescriptions or orders in the chart and often do not leave a contact number. If there is a query about the drug, then the pharmacist and nurse are left on their own, and consequently, the patient misses out on the medication.

Who Is to blame: The Healthcare Professional or the System?

In the past when medication errors occurred, the individual who caused it was usually blamed for the mishap. Medication errors related to employees may be due to the following:

  • Negligence
  • Forgetful
  • Hurrying
  • Poor motivation
  • Vengeance
  • Carelessness

In such situations, the disciplinary actions may include:

  • Blame and shame
  • Loss of privileges
  • A threat of a medical malpractice lawsuit
  • Relief from certain duties
  • Transfer to another department

This culture of blame has shifted, and medication errors are believed to be a systemic problem. Errors in the system may be viewed as the end result and not the cause. Thus, rather than focusing on changing the behavior of every healthcare worker, hospitals are now trying to understand how the system failed. This approach is designed to introduce barriers and safeguards at every level so that a mistake can be caught before the drug is given to the patient. In many cases, mistakes are made by some of the well-trained healthcare professionals, and rather than blame them, one should try and understand why the error occurred. In many cases, errors occur in recurrent patterns, irrespective of the healthcare worker involved. [12]

Other Issues

Other Strategies to Reduce Medication Errors

Over the years, hospitals have developed strategies to prevent medication errors. Some of these strategies include the following:

  • Double check dosing and frequency of all high-alert medications. A list of high alert medications is provided by the Institute of Safe Medication Practices.
  • If unsure about the drug or the dose, speak to the pharmacist.
  • If the writing is illegible, do not give the medication in the belief that you think you know what it is. Call the healthcare provider to confirm the drug or dose.
  • Recheck the calculation to ensure that the patient will get the right therapeutic dose.
  • Ask another clinician to recheck your calculations. [13]

Pearls of Wisdom

Preventing medication errors

  • Always write one prescription for each medication.
  • Besides signing the prescription, always circle your name on the preprinted prescription pad.
  • Do not hesitate to check the dose and frequency if you are not sure.
  • Always consider the fact that each medication has the potential for adverse reactions.
  • Do not use drug abbreviations when writing orders.
  • Always add the patient’s age and weight to each prescription.
  • Check for liver and renal function before ordering any medication.
  • Spell out the frequency and route of dosage; do not use abbreviations.
  • Always specify the duration of therapy; do not say give out "XXX" number of pills.
  • Always be aware of high-risk medications.
  • When writing a prescription, state the condition being treated.

Enhancing Healthcare Team Outcomes

Writing prescriptions and orders for medication is an everyday part of the job for many healthcare workers including nurse practitioners. However, the increased demands to see more patients who require many medications often becomes monotonous, and one can become careless. The majority of healthcare workers never anticipate an adverse drug event, and consequently, rarely check back with the pharmacists for drug interactions. With a high number of medication-related errors, healthcare workers are under great scrutiny to change their work habits and adopt a culture of safety when writing drug orders and prescriptions. Though there is no single way to eliminate all drug errors, healthcare workers can reduce the errors by becoming more cautious and interacting closely with other practitioners, pharmacists, and patients. Open and direct communication is one way to bridge the safety gap.


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Medication Errors - Questions

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Which of the following are reporting requirements for misadministrations?



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Which of the following is NOT an example of a misadministration?



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A 45 year old female has been hospitalized for uncontrolled diabetes. She has a history of several hospitalizations for noncompliance and failure to take her prescribed insulin. The provider ordered 10 units of regular insulin subcutaneous stat after evening rounds. Which of the following actions by the nurse should be questioned?



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Administer 20 gtt of timolol maleate ophthalmic solution each eye, daily, signed by the provider. Which components of the medication order should be questioned?



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Look-alike and sound-alike medications pose a risk during medication administration. What are some drugs that fit into this category? Select all that apply.



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Medication Errors - References

References

Wheeler AJ,Scahill S,Hopcroft D,Stapleton H, Reducing medication errors at transitions of care is everyone's business. Australian prescriber. 2018 Jun     [PubMed]
Whittaker CF,Miklich MA,Patel RS,Fink JC, Medication Safety Principles and Practice in CKD. Clinical journal of the American Society of Nephrology : CJASN. 2018 Jun 18     [PubMed]
Rodziewicz TL,Hipskind JE, Medical Error Prevention null. 2018 Jan     [PubMed]
Cohen MR,Smetzer JL, ISMP Medication Error Report Analysis. Hospital pharmacy. 2017 Jun     [PubMed]
Nuckols TK,Smith-Spangler C,Morton SC,Asch SM,Patel VM,Anderson LJ,Deichsel EL,Shekelle PG, The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic reviews. 2014 Jun 4     [PubMed]
Bonetti AF,Reis WC,Lombardi NF,Mendes AM,Netto HP,Rotta I,Fernandez-Llimos F,Pontarolo R, Pharmacist-led discharge medication counselling: A scoping review. Journal of evaluation in clinical practice. 2018 Jun     [PubMed]
Samaranayake NR,Cheung DS,Lam MP,Cheung TT,Chui WC,Wong IC,Cheung BM, The effectiveness of a 'Do Not Use' list and perceptions of healthcare professionals on error-prone abbreviations. International journal of clinical pharmacy. 2014 Oct     [PubMed]
Cornuault L,Mouchel V,Phan Thi TT,Beaussier H,Bézie Y,Corny J, Identification of variables influencing pharmaceutical interventions to improve medication review efficiency. International journal of clinical pharmacy. 2018 Jun 2     [PubMed]
Cheng R,Yang YD,Chan M,Patel T, Medication Incidents Involving Antiepileptic Drugs in Canadian Hospitals: A Multi-Incident Analysis. Healthcare quarterly (Toronto, Ont.). 2017     [PubMed]
Almeida TA,Reis EA,Pinto IVL,Ceccato MDGB,Silveira MR,Lima MG,Reis AMM, Factors associated with the use of potentially inappropriate medications by older adults in primary health care: An analysis comparing AGS Beers, EU(7)-PIM List , and Brazilian Consensus PIM criteria. Research in social     [PubMed]
Di Simone E,Giannetta N,Auddino F,Cicotto A,Grilli D,Di Muzio M, Medication Errors in the Emergency Department: Knowledge, Attitude, Behavior, and Training Needs of Nurses. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine. 2018 May     [PubMed]
Lenz JR,Degnan DD,Hertig JB,Stevenson JG, A Review of Best Practices for Intravenous Push Medication Administration. Journal of infusion nursing : the official publication of the Infusion Nurses Society. 2017 Nov/Dec     [PubMed]
Wittich CM,Burkle CM,Lanier WL, Medication errors: an overview for clinicians. Mayo Clinic proceedings. 2014 Aug     [PubMed]

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