Medication Errors

The Nationla Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defines a medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, consumer

Medication errors, whether they are errors in prescribing, dispensing, or adminstering medication can lead to adverse drug events (ADES).

An adverse drug event (ADR) in a pharmacy refers to any unexpected, harmful or negative reaction that occurs as a result of taking medication. This can include side effects, allergic reactions, medication errors, or interactions between different drugs.

Adverse drug events can range from mild to severe and can lead to hospitalization or even death in some cases. It is important to be vigilant in identifying and preventing ADEs, by reviewing patients’ medical histories, monitoring medication use, and providing education and counseling to patients on how to use their medications safely and effectively.

Three Main Causes of Errors:

1. Organizational Failure

2. Technical Failure

3. Human Failures

   a. incomplete information error

   b. incorrect assumption error

   c. selection error

   d. capture error

   e. rushed error

   f. distraction error

   g. fear error

Technical Errors

• Wrong Drug Error

• Adverse Drug Error

• Mislabeling Error

• Wrong Formulation Error

• Documentation Error

• Medication Education Error

• Contaminated Product Error

Administrative Errors

1. Wrong time error

2. Extra dose error

3. Omission error

How to Avoid Medication Errors:

Implement a double-check system:

Have a second pharmacist or pharmacy technician double-check all medications before they are dispensed to ensure accuracy.

Use Technology:

Utilize pharmacy software and electronic prescription systems to reduce errors caused by illegible handwriting or misinterpretation of prescription information.

Communicate with patients:

Talk to patients about their medications, including dosage and administration instructions, to ensure they understand how to take their medications correctly. We are all on the same healthcare team.

How a clear labeling system:

Ensure all medications are properly labeled with clear and easy-to-understand instructions.

Perform regular inventory checks:

Check medication inventory regularly to avoid dispensing expired or recalled medications.

Stay up-to-date with current medication information:

Stay informed about current medication information, including new drugs, dosages, and potential side effects.