“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 health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.”
How Do Medication Errors Occur?
The provision of drug therapy by a medical provider to a patient is a complex process. Errors can occur at any step along the way, from prescribing to the ultimate provision of the drug to the patient. Common causes of medication error include incorrect diagnosis, prescribing errors, dose miscalculations, poor drug distribution practices, drug and drug device related problems, incorrect drug administration, failed communication and lack of patient education.
One of the largest causes of therapeutic medication misadventures is incorrectly prescribed medication. The number of patient deaths resulting from drug errors has increased from 198,000 in 1995 to 218,000 in 2000. The cost of these misadventures to the US economy is more than $177 billion per year.
Preventable errors occur because systems for safely prescribing and ordering medication are not appropriately used.
A widely recognized cause of error is illegible handwritten prescriptions.
●Errors may result from insufficient or missing information about co-prescribed medications, past dose-response relationships, laboratory values and allergic sensitivities.
●Errors in prescribing can occur when an incorrect drug or dose is selected, or when a regimen is too complex.
●When prescriptions are transmitted orally, sound-alike names may cause error.
Similarly, drugs with similar-looking names can be incorrectly dispensed when prescriptions are handwritten.
●Errors may occur because a prescription is never transmitted to a pharmacy, or a prescription is never filled by the patient.
●Physician sampling of medications can contribute to medication errors due to the lack of both adequate documentation and drug utilization review.
Attitudes About Medication Errors
Medical professionals, including physicians, nurses and pharmacists, do not deliberately commit medication errors. They are trained to deliver “error free” health care. However, when errors are discovered, there is an attitude of placing “blame” on the professional(s) involved in the incident. Formal punishment by the individual’s profession is sometimes administered, resulting in fines, license suspension or even license revocation. More importantly, the individual may be punished by the lost respect of his or her fellow health care professionals, which may be even more devastating than a professional reprimand.
Where medication errors are concerned, the question of who was involved is of less importance than what, how and why the system went wrong.8 An investigation of medication errors should begin with an analysis of the drug use and delivery channels within a health care system, rather than result in punitive action directly targeted to the health care provider involved with the error. Although there is no acceptable level of error within the medical care system, the goal of health care organizations should be to evaluate errors when they occur and to make changes in the drug delivery process to prevent them from reoccurring in the future or elsewhere.
Keys to Error Prevention
Health care professionals must provide adequate patient education about the appropriate use of their medications as part of any error prevention program. Proper education empowers the patient to participate in their health care and safeguard against errors. Some examples of instructions to patients that can help prevent medication errors are:
1. Know the names and indications of your medications
2. Read the medication information sheet provided by your pharmacists
3. Do not share your medications
4. Check the expiration date of your medications and dispose of expired drugs
5. Learn about proper drug storage
6. Keep medication out of the reach of children
7. 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.
One way in which electronic technology can improve patient safety and reduce medication errors is 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.
●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. E-prescribing Utilization of electronic prescribing by entering orders on a computer, better known as Computerized Physician Order Entry (CPOE), is a technology that could help prevent many medication errors.
Due to the technology of the electronic prescription record, pharmacists are able to conduct prospective online drug utilization reviews (DUR). The online DUR process allows the pharmacist to conduct a review of the prescription order at the time it is presented for filling and proactively resolve potential drug-patient problems such as drug-drug interactions, over-use, under-use and medication allergies. 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.
●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.15 Many automated dispensing systems utilize the bar coding technology discussed earlier to ensure the right drug, dose and dosage form is used.
●Internal Quality Control Procedures:
Most medication dispensing settings have developed quality evaluation procedures. These practices provide workflow evaluation and error reporting analyses, which lead to excellent protection from medication error. These procedures and evaluations have led to several changes in standard practice for ambulatory pharmacy, generally adopted as acceptable professional practice. These changes have provided additional safety checks, such as image displays, as part of the final dispensing review process, and the addition of descriptive text on prescription labels. These practices not only allow for final dispensing checks, but also allow for patient monitoring of consistency between label description and vial contents.
Proactive system interventions also provide additional error prevention protection. Many pharmacies and commercial dispensing systems now provide messaging during the drug selection process. When a drug is known to be subject to look-alike, sound-alike drug name confusion, the dispenser is alerted to double check that the appropriate agent has been chosen.
In summary, medication errors are an unfortunate part of the health care delivery system. Health care provider attitudes must change in the approach to prevention of these errors. Patient education is an important aspect of any program to prevent medication misadventures.