Comprehensive Guide to Medication Errors: Definitions, Causes, Prevention, and Reporting

What is a medication error?

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is under the control of a healthcare professional, patient, or consumer.

What are common causes of medication errors?

Poor communication, verbal orders, poor handwriting, look-alike/sound-alike drugs, and polypharmacy.

How many deaths do medication errors cause annually?

More than 7,000 deaths annually.

How many preventable medication errors harm patients each year in the U.S.?

At least 1.5 million.

How many medication errors can hospitalized patients expect to be exposed to daily?

About 1 medication error per day.

For every medication error that harms a patient, how many errors do not cause harm?

About 100 mostly undetected errors.

What is a major cause of dispensing errors?

Failure to double-check orders, medications, and labels.

What role do distractions and interruptions play in medication errors?

They are a major cause of dispensing errors.

What is the effect of interruptions on error rates?

More than double the chance of making an error.

What is the overall dispensing error rate in studies?

3.23%.

What is the error rate with interruptions?

6.65%.

What is the error rate with distractions?

6.55%.

What are the five stages of the medication process?

Ordering/Prescribing, Transcribing and Verifying, Dispensing and Delivering, Administering, Monitoring.

What is a recommendation to reduce medication errors?

Always use two patient identifiers.

How can technology help reduce medication errors?

Through electronic prescribing, computerized order entry, bar coding, automation, and medication error reporting.

What is the Teach-Back Method in patient counseling?

The patient repeats information to confirm understanding.

What should be verified to prevent medication errors?

Allergy information and original prescriptions.

What are the 4 A's of mindfulness?

Alert, Attentive, Aware, Avoid distractions.

What does the 'A' in the ACTION components of a culture of safety stand for?

Accountability.

What does the 'C' in the ACTION components stand for?

Communication with Respect.

What does the 'T' in the ACTION components represent?

Teamwork.

What does the 'I' in the ACTION components stand for?

Improving the System.

What does the 'O' in the ACTION components represent?

Openness/Transparency.

What does the 'N' in the ACTION components stand for?

Near Miss/Event Reporting.

What is Category A in the NCC MERP Error Classification?

Circumstances exist that could cause an error.

What does Category C in the NCC MERP Error Classification indicate?

Error reached patient but caused no harm.

What does Category E in the NCC MERP Error Classification indicate?

Temporary harm requiring intervention.

What does Category I in the NCC MERP Error Classification indicate?

Error contributed to death.