• Section 8. Reducing Medication Errors

    Challenges to Preventing Medication Errors


    The National Coordinating Council for Medication Error Reporting and Prevention 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, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."28


    There are numerous challenges to preventing medication errors. It is common practice, depending on the healthcare setting, to have many individuals involved in the prescribing, dispensing and administration of a medication (e.g., physicians, nurses, pharmacists, and the patient) with the potential for an error to occur at any step in the process. Healthcare professionals should be aware of the sources and types of medication errors so that they may better identify and avoid potential problems before they occur.


    Case Examples: Nursing Home Fined for Three incidents of Medication Errors

    These are examples of facilities fined for making medical errors that endangered patients health.

    On May 7, Walnut Hill Care Center in New Britain, NJ, was fined $500 in connection with three incidents of medication errors. On Dec. 27, one resident was given the wrong medication and was hospitalized for lethargy, records show.

    The state also found that a resident with diabetes was not given prescribed medication from May 12 to May 19 because the medication required an authorization from the facility to be reordered. The resident’s doctor also was not told that the medication had not been given.

    In the case of a resident who lost eight pounds in 15 days, medical personnel were not notified of the significant weight loss and the weight loss was not entered into a computer system that was being checked nightly by a dietitian.

    On June 25, a licensed practical nurse admitted giving one resident the medications of another resident while being distracted, records show. The resident was hospitalized for nausea, and records show the nurse was fired.

    Reducing Medication Errors

    Most of the time medications are beneficial, or at least they cause no harm, but on occasion they do injure the person taking them. Some of these “Adverse Drug Events [ADEs],” as injuries due to medication are generally called, are inevitable - the more powerful a drug is, the more likely it is to have harmful side effects, for instance - but sometimes the harm is caused by an error in prescribing or taking the medication, and these damages are not inevitable. They can be prevented.

    The American Hospital Association lists the following as some common types of medication errors:

    • Incomplete patient information (not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results, for example);
    • Unavailable drug information (such as lack of up-to-date warnings);
    • Miscommunication of drug orders, which can involve poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations;
    • Lack of appropriate labeling as a drug is prepared and repackaged into smaller units; and
    • Environmental factors, such as lighting, heat, noise, and interruptions that can distract health professionals from their medical tasks.

    There are many steps that healthcare professionals can take to reduce the occurrence of medication errors at the point of prescribing a medication. Two major sources of errors in prescribing are poor penmanship and the use of error-prone abbreviations. For instance, healthcare professionals should be cognizant of their penmanship and use computerized prescriber order entry if available, to lessen any confusion that may result from poorly written prescriptions.


    Computerized Physician Order Entry (CPOE) Systems

    The Leapfrog Group’s report on Computerized Physician Order Entry (CPOE) Systems and Medication Errors, shows a record number of U.S. hospitals are using technology to reduce potential medication prescribing errors; however, these systems fail too often, jeopardizing patients’ safety. The results demonstrate that some U.S. hospitals are better at preventing medication errors, the leading cause of harm to patients.27

    The in-depth examination looked at the use of CPOE systems by hospital clinicians, who directly enter medication orders into a computer system and electronically transmit them to a pharmacy. Medication errors are the most common mistakes made in hospitals. In fact, each year, serious, preventable medication errors affect 3.8 million patients.

    Errors such as dosing, drug allergies, harmful drug interactions or dispensing problems are frequent, and the harm they cause can be significant, even resulting in death. As nearly 90 percent of medication errors occur during manual ordering and transcribing, effective use of CPOE systems can help reduce the risk of the wrong drug or dose being delivered to a patient.

    “Not only are medication errors dangerous, but these preventable incidents are expensive. Each error is estimated to cost nearly $4,300, or nearly $16.4 billion dollars annually,” said Jennifer Schneider, M.D., M.S., Chief Medical Officer for Castlight Health.

    Prescribing and Dispensing Medications

    Another important step in reducing the number of medication errors will be to make greater use of information technologies in prescribing and dispensing medications. Doctors, nurse practitioners, and physician assistants, for example, cannot possibly keep up with all the relevant information available on all the medications they might prescribe—but with today’s information technologies they don’t have to. By using point-of-care reference information, typically accessed over the Internet or from personal digital assistants, prescribers can obtain detailed information about the particular drugs they prescribe and get help in deciding which medications to prescribe.

    Even more promising is the use of electronic prescriptions, or e-prescriptions. By writing prescriptions electronically, doctors and other providers can avoid many of the mistakes that accompany handwritten prescriptions, as the software ensures that all the necessary information is filled out—and legible. Furthermore, by tying e-prescriptions in with the patient’s medical history, it is possible to check automatically for such things as drug allergies, drug-drug interactions, and overly high doses. In addition, once an e-prescription is in the system, it will follow the patient from the hospital to the doctor’s office or from the nursing home to the pharmacy, avoiding many of the “hand-off errors” common today.

    The following illustration is an example of a hand-written prescription for Metadate ER 10 mg tablets. Metadate is a drug used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD). Due to the similarity in name, poor penmanship and the omission of the modifier "ER", the pharmacy filling the prescription incorrectly dispensed methadone 10 mg tablets. Methadone is a morphine-based product used as a heroin substitution therapy and analgesic. Methadone is not used for the treatment of ADHD.








    Case Examples: Nursing Home Fined Following Medication Errors, Injuries

    These are examples of facilities fined for making medical errors that endangered patients health.

    Regency Heights of Danielson, NJ, was fined $1,090 on July 1 in connection with an incident in which a resident with diabetes was given ten times the amount of insulin that had been prescribed by a doctor, DPH records show.

    The resident was hospitalized after receiving the wrong dose four times on Dec. 2 and Dec. 3, 2013, records show.

    A registered nurse said when she looked at the physician’s order, she thought it said 40 units, instead of four, so she transcribed it in the medical administration record as 40, DPH records show. The director of nursing said the nurse should have asked another nurse about the dosage or called the doctor.

    Product Labeling and Packaging

    Medication errors may be related to professional practice, the product itself, and/or the procedures and systems related to distribution, dispensing and administration of drugs. For instance, drugs may be given names, shapes, or colors similar to other medications. As illustrated below, similarities in product packaging may result in confusion among healthcare professionals charged with dispensing drugs or among patients taking drugs at home.28

    The following illustration is an example of similar looking packaging from the same manufacturer for two unrelated drugs. On the left are 50 mg tablets of hydroxyzine HCL, a sedating antihistamine. On the right are 50 mg tablets of hydralazine HCL, an antihypertensive drug. The packaging of these products may lead to a serious medication error.


    Drug Names

    In addition to ensuring that drug labels contain accurate, up-to-date information, FDA also takes an active role identifying factors that may contribute to the incorrect distribution, dispensing, or taking of a medication.

    The FDA reviews drug names from both a promotional and safety perspective. The safety review focuses on the avoidance of error. FDA considers whether the proposed name looks and sounds like the names of drug products that are already marketed in the US and evaluates this risk using Failure Mode and Effects Analysis, a process by which potential failures in a system (e.g., drug design) and the effects of such failures (e.g., medication errors) can be assessed.

    Bar Codes

    In 2004, FDA published a final rule requiring a bar code be placed on all drugs distributed and used in hospital settings. According to the rule, manufacturers, re-packers, re-labelers and private label distributors of drug products commonly used in hospitals must place a bar code on their product. The function of the bar code is to reduce error by increasing standardization among products so that, in conjunction with bar code scanning technology, the right patient can get the right drug at the right time.29

    Section 7. Building a Safety CultureSection 9: Academy of Nutrition and Dietetics Medical Nutrition Therapy Documentation