Medication Errors

Chief Advisor(s): Michael A.E. Ramsay, MD, FRCA ; Jerika T. Lam, PharmD. APh, AAHIVP, FCSHP
Publication ID: 7601101755
Published on: August 2023
Major Revision: April 17, 2024

Overview

A 2016 study showed one out of every two surgeries has a medication error or an adverse drug event, a major contributing factor to medication errors being the leading preventable cause of death for patients in the US. In addition to the high rate of surgery-related medication errors, drug infusion pump errors are another significant source of patient harm. Beyond the human toll, medication errors cost of about $42 billion a year globally. To reduce medication errors, hospitals and healthcare systems can implement a host of new approaches and technologies, such as automated infusion and IV injectable technologies, electronic medical records, and checklists. This blueprint outlines a number of protocols to help improve quality of care and to foster a culture of safety around medication practices and procedures.

Frontline staff

Unit Managers

Hospital Executives

Patient & Families

Resources

Frontline staff

This blueprint outlines the steps that frontline staff can follow to prevent medication errors:

To ensure best patient care:

  1. Use systematic protocols for medication administration, including checklists for writing and filling prescriptions, drug administration and patient transitions of care, and other quality assurance tools. These include:
    1. Utilizing a patient safety electronic system for a medication management system
    2. Implementing a drug library system
    3. Confirming drug dosing with the electronic medication management system
    4. Using barcoding for identification in the medication administration process
    5. Checking patient’s allergy profile before prescribing medication, which should be backed up by the electronic management system
    6. Ensuring appropriate training and safe operation of automated infusion technologies
    7. Distinguishing “look-alike, sound-alike” medications with appropriate labeling, package design, barcoding, and storage
  2. Practice the 6 Patient Rights on Medication Administration: right patient, right drug, right dose, right route, right time of administration, and right documentation. All care providers should use this simple checklist.
  3. Follow best practices to prevent medication errors during transitions of care (see below).
  4. Use Computerized Provider Order Entry (CPOE) reporting systems and quality assurance reports to audit compliance.
  5. Use Clinical Decision Support (CDS) systems where possible.

To ensure safety during transitions of care:

Consider the following high-risk medication groups:

  1. Analgesics
    1. For opioids, consider electronic monitoring for respiratory depression.
    2. Take into account all pain medications, including over-the-counter (OTC), that can put patients into respiratory depression because of additive somnolence effects.
    3. Be aware of the risks of exceeding the recommended daily maximum dose of
  2. Antidiabetics
    1. Prior to initiating or resuming metformin, consider kidney function is
    2. Adjust insulin based on blood glucose and consider continual monitoring of blood glucose.
  3. Anticoagulation/Antiplatelet
    1. Check and monitor INR levels, renal function, OTC medication use (i.e., NSAIDs).
    2. Antibiotics
    3. Determine appropriate antibiotic and duration of therapy for the infection.
    4. Ensure pertinent labs are ordered (i.e., vancomycin and aminoglycoside concentrations).
    5. Obtain a thorough antibiotic history within the past three months.

Coordinate appropriate follow-up and monitoring, such as:

  1. Labs: INR, digoxin levels, electrolytes, blood sugar, antibiotic concentrations, thyroid levels
  2. Chronic disease state management, such as heart failure, diabetes, asthma, and COPD
  3. Changes in health status, including changes in weight, that could affect medication dose
  4. Renal and liver function
  5. Conditions that could affect the patient’s ability to take medications by mouth, injection, or inhalation routes
  6. Ordering needed medical equipment, such as a nebulizer, diabetic supplies, and IV antibiotic
  7. Checking patient’s immunization record to ensure patients receive and are educated on scheduled vaccines (influenza, pneumonia, etc
Unit Managers

This guide outlines the steps that managers can follow to prevent medication errors:

  1. Store medication in an electronic dispensing machine so medication will only be dispensed when an order is provided.
  2. Create protocols:
    1. Create a universal checklist for medication administration that includes:
    2. Patient name
    3. List of patient’s current medicines
    4. Medication to be given and its:
      1. Dose
      2. Route
      3. Timing
      4. Documentation
    5. Systematize tools and practices, including checklists, for:
      1. Patient allergy and medication interaction checks on every patient
      2. Computerized Provider Order Entry (CPOE)
      3. Medication barcoding
      4. Patient education and adherence
      5. Correct and on-time medication administration
    6. Practice hand hygiene when giving medication such as tablets, capsules, and pills by hand, such as wearing gloves instead of using bare hands.
    7. Use standardized order sets where possible.
    8. When possible, let patients know what medication they are getting and what it is for.
  1. Engage staff and use data to find areas for improvement
    1. Use technology to standardize Computerized Provider Order Entry (CPOE), reporting systems, and quality assurance reports to audit compliance.
    2. Use Clinical Decision Support (CDS) systems where possible.
    3. Review monitoring and reporting results at medical staff meetings and education sessions as a part of Continuous Quality Improvement (CQI).
    4. Use patient stories—in written and video form—to identify gaps and inspire change in your staff.
    5. Measure outcomes. 
  1. Provide staff training
    1. Create a multidisciplinary team that includes physicians, nurses, pharmacists, and information technology personnel.
    2. Assess opportunities to reduce medication errors using a self-assessment process.
    3. Create and deliver monthly or quarterly education on medication error and patient safety updates.

Note the following:

The top medication classes and triggers are:

  1. Opioids
  2. Sedatives and hypnotics (including propofol)
  3. Anticoagulants
  4. Antimicrobials (including antivirals and antifungals)
  5. Antidiabetic medicines (including insulin and other injectable and oral medications)

Key performance indicators

Adverse drug event (ADE) with harm to patient (Category E or higher on NCC-MERP classification) that is preventable (i.e., not an unknown first-time reaction to a medication)

Initial or baseline measurement will show ability to capture ADE information, since most are voluntarily reported. Over time, decreases in this rate can show lives spared harm. To ensure that reductions are not due to decreased reporting, a control measure should also be measured.

Outcome measure formula

  1. Numerator: Number of reported adverse drug events with harm, as defined above (by class or medication)
  2. Denominator: Number of doses administered (by medication or class of medication) *Rate is typically displayed as ADE with harm/1,000 doses

Metric recommendations

  1. Indirect impact (preventable rate): All patients
  2. Direct impact (non-preventable rate): All patients prescribed medications

Control rate calculation

  1. Numerator: Number of ALL reported errors and adverse drug reactions (including harm and NOT causing harm or “near misses”)
  2. Denominator: Number of doses administered over a time period

Control ADE rate should be consistent or increase with corresponding decrease in ADE with harm.

Data collection

ADE reporting information is based on volunteer reporting and accuracy of people verifying reports, preferably from between pharmacy and the medication error reporting and prevention (MERP) program.

Medication usage information is usually collected from billing information rather than medication orders (more accurate if patient received the dose or not).

If medication usage information is not available, the denominator could be per 1,000 patient days. This can track over time, especially for all ADE reporting; however, it will not adjust ADE rate for high- or low-utilization medications.

Scales

The Adverse Drug Reaction Probability Scale (Naranjo) determines the causality of an ADR or how likely the drug is the true cause of the ADE (Adverse Drug Reaction Probability Scale).

Hospital Executives

This protocol outlines the steps that executives can follow to prevent medication errors:

Globally, the total cost associated with medication errors is estimated at $42 billion each year, and expenses can occur at different stages of the medication-use process. Medication errors could cause patients to experience physical and psychological pain and suffering and potentially be fatal. Medication errors could result from human factors and a flawed system with inadequate infrastructure to detect mistakes. Preventing medication errors will improve the quality and safety of healthcare and lower costs. It also helps create a safety culture that promotes patient safety and quality of care while reducing preventable risks and harm.

Some types of medication errors are more common or severe. For example:

  • Drug infusion pump errors are common and may have serious consequences. Some drug infusion pumps are complex and may have poorly designed features for the user, which make it difficult for the user to program and use it. Patients who get infused medicines are often critically ill and taking multiple medicines, which further increases the chance of error and adverse events.
  • Surgery has high rates of medication errors with a higher severity level. This is due to a high-stress environment and lack of computerized order entry, pharmacy approval processes, or a second check by another person prior to giving the medicine. Electronic technology should be used in both the operating room and anywhere else it’s possible to prevent medication errors.

Hospitals and healthcare systems can use a variety of new approaches to reduce medication errors, such as automated infusion and IV injectable technologies, electronic medical records, and checklists.

Hospital governance, senior administrative leadership, clinical leadership, and safety/risk management leadership need to work collaboratively to reduce medication errors. 

Show leadership’s commitment to reducing medication errors:

  1. If a medication error occurs, examine the event to see if this was a process error or a failure to maintain a safety culture. In other words, would another person in the same situation make the same mistake? If so, the process must be fixed.
    1. Put in place a “just culture.”
  2. Educate and empower patients, healthcare professionals, researchers, and
  3. Provide information so that leadership and all healthcare professionals fully understand the performance gaps in their own area of care.
  4. Have all clinical/safety leadership staff endorse the plan to ensure it’s put into place across all providers and systems.

Create the infrastructure needed to make changes:

  • Identify evidence-based approaches to medication safety that reduce preventable deaths and can be applied in multiple care settings and for multiple patient types.
  • Set a firm date to begin the safety plan, with measurable outcomes and milestones.
  • Get approval for the plan’s budget from governance boards and leadership.

 

Patient & Families

The following guide outlines the steps that patients and patient families can follow to prevent medication errors: 

  • Make sure to keep medication in a secure place.
  • Keep a list of the medications you are taking and the schedule for taking them.
  • Make sure the prescriber knows your allergies.

Below is a list of questions to ask the attending clinician or pharmacist.

  1. What is the name and purpose of the medication?
  2. What is the correct dosage and how often should I take it?
  3. Should I take this medication with or without food?
  4. Are there potential side effects, and what should I do if I experience them?
  5. Are there any interactions with my other medications or supplements?
  6. Can you provide written instructions for taking this medication?
  7. Is there a specific time of day I should take it?
  8. How long should I continue taking this medication?
    1. If so, will I need refills?
  9. What should I do if I miss a dose?

 

Resources

Bekes J, et al. Pediatric Medication Errors and Reduction Strategies in the Perioperative Period. (2021) https://pubmed.ncbi.nlm.nih.gov/34342569/

Bourne SR, et al. Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis. (2022)  https://qualitysafety.bmj.com/content/31/8/609.abstract

Bowdle A, et al. Take action now to prevent medication errors: lessons from a fatal error involving an automated dispensing cabinet. (2022) https://pubmed.ncbi.nlm.nih.gov/36333160/

Jessurun J, et al. Effect of automated unit dose dispensing with barcode scanning on medication administration errors: an uncontrolled before-and-after study. (2021) https://pubmed.ncbi.nlm.nih.gov/34662396/

Kirkendall E, et al. Human-Based Errors Involving Smart Infusion Pumps: A Catalog of Error Types and Prevention Strategies. (2020)  https://pubmed.ncbi.nlm.nih.gov/32797355/

Leapfrog Group. Prepare for CPOE Tool. https://leapfroggroup.org/survey-materials/prepare-cpoe-tool

Moureaud C, et al. Guidelines for Leading a Safe Medication Error Reporting Culture. (2021) https://pubmed.ncbi.nlm.nih.gov/34720167/

Trockel M, et al. Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors. (2020)  https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2773777

Westbrook J, et al. Changes in medication administration error rates associated with the introduction of electronic medication systems in hospitals: a multisite controlled before and after study. (2020) https://pubmed.ncbi.nlm.nih.gov/32796084/

World Health Organization. Medication Safety in Polypharmacy. (2019) https://iris.who.int/bitstream/handle/10665/325454/WHO-UHC-SDS-2019.11-eng.pdf

World Health Organization – Medication Without Harm  https://www.who.int/initiatives/medication-without-harm#:~:text=Globally%2C%20the%20cost%20associated%20with,of%20the%20medication%20use%20process.

 

CLOSE