SUSAN DEPASQUALE, MSN, FPMHNP-BC
Susan DePasquale is a board-certified Family Psychiatric Mental Health Nurse Practitioner. Her current practice is with youth and adults who have mental illnesses in both inpatient and outpatient settings, including telepsychiatry for Montana and Wisconsin communities. She completed her Master of Art in Political Science at the University of Victoria, British Columbia, Master of Science in Nursing at Seattle Pacific University in Seattle, Washington, with a focus in neurogastroenterology, and the Post-Master of Science in Nursing at the Montana State University in Bozeman, Montana with a focus in psychiatry. She has worked with small and rural healthcare teams in British Columbia and the Northwest Territories, Canada, and in teaching and research hospitals such as Providence Health and Virginia Mason Medical Center Digestive and Liver Disease Departments in Seattle. Since 2012, she has been actively involved in online continuing education program development for nurses and health teams.
AMANDA MAYER, PharmD
Amanda Mayer is a graduate of the University of Montana, Skaggs School of Pharmacy. She has clinical experience working in inpatient mental health, which is her passion. She has also done fill-in work at retail pharmacies throughout her career. Amanda appreciates the wide variety of professional opportunities available to pharmacists. Amanda loves spending time with her family and spends most of her free time exploring new restaurants, hiking in the summer, and snowboarding and cross-country skiing in the winter.
Medication errors may occur at any time during the prescription, administration, and monitoring of a drug. It is a preventable event that may harm a patient. The identification and prevention of medication errors require an understanding of the root causes of medication errors. Once root causes are identified, a pharmacist may implement procedures and protocols that reduce and prevent medication errors and that promote patient safety. Pharmacists can work collaboratively with healthcare teams to reduce and prevent future medication errors.
RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.
Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is
Pharmacy Technician 0669-0000-22-036-H05-T
Credits: 2 hours of continuing education credit
Type of Activity: Knowledge
Media: Internet Fee Information: $6.99
Estimated time to complete activity: 2 hours, including Course Test and course evaluation
Release Date: September 6, 2022 Expiration Date: September 6, 2025
Target Audience: This educational activity is for pharmacists.
How to Earn Credit: From September 6, 2022, through September 6, 2025, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Study the section entitled “educational activity;” and
Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
Learning Objectives: Upon completion of this educational activity, participants should be able to:
Identify and define medication errors
Identify the root causes of medication errors
Describe and know how to reduce and prevent medication errors
Identify and Describe the pharmacist’s role in educating patients to help patients participate in preventing medication errors
The following individuals were involved in the development of this activity: Susan DePasquale, MSN, PMHNP-BC, Amanda Mayer, PharmD, and Jeff Goldberg, PharmD. There are no financial relationships relevant to this activity to report or disclose by any of the individuals involved in the development of this activity.
Medical errors are a significant problem in the healthcare system. One of the most pervasive medical errors that are responsible for considerable patient harm is the medication error. A medication error may occur at any point from prescription, administration, and through monitoring of a drug. Medication errors may be reduced or prevented with an understanding of the root causes of medication errors, followed by the implementation of policies, procedures, or systemic changes that can address these root causes and create a safer health care system for patients.
Medication Errors: Definition and Scope
Medication errors fall within the broader concept of medical errors. Medical errors were highlighted by the Institute of Medicine (IOM) over 20 years ago in its seminal monograph, To Err is Human: Building a Safer Health System.1 The Institute of Medicine (IOM) reported that 7% of all hospital admissions experience a serious medication error.1 In the United States, 7,000 to 9,000 people die annually from medication errors.2 The scope of the problem related to medication errors is further highlighted by the fact that the
U.S. Food and Drug Administration (FDA) receives over 100,000 reports of suspected medication errors annually.3 In addition to the human harm, medication errors exact an economic cost of about $42 billion globally on an annual basis.2
A medication error is defined by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) 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 health care professional, patient, or consumer.”4 This means that a medication error does not necessarily result in patient harm.4 This point is emphasized in an alternative definition of a medication error that describes it as “any error in the process of ordering or delivering a mediation regardless of whether an injury occurred or the potential for injury was present.”5
When a medication error results in patient harm, it is then categorized as an adverse drug event (ADE).6 An ADE is a broad term that not only includes medication errors that result in harm but patient harm caused by an adverse drug reaction (ADR) when a drug was used as intended.6 However, the terms ADE and ADR have often been used interchangeably, which has led to confusion around their precise meanings.6 While medication errors were called ADEs, ADRs were historically limited to events that arose only from appropriate uses of medications. This distinction appears to have faded. By 2010, the term ADR was expanded to include medication errors.7 This means that in the literature, a medication error may be referred to as an ADE or ADR.6
An example of a medication error that leads to an ADE or ADR is the case where a patient receives a medication even though the patient has a known allergy to the medication. This error could occur because the allergy was not documented or a pharmacist and/or physician bypassed warnings about the allergy.7
Medication errors can be inconsequential, or they may have mild outcomes for a patient; however, medication errors may also have serious consequences that can include a life-threatening medical condition, hospitalization, and possibly disability or death.3 When a medication error occurs with a pregnant patient, it may result in a birth defect or other harm to the developing fetus.3
Given the potentially serious, negative outcomes that may result from medication errors, the healthcare industry has worked to reduce medication errors and thereby create a safer healthcare system for patients and the public at large. This effort includes identifying the common types of medication errors, the root causes of medication errors, and systemic changes that can be used to address these root causes.
Types of Medication Errors
The NCC MERP states that medication errors may arise within a professional practice, with the use of health care products, and from health care procedures and systems. Medication errors may occur during prescribing, order communication and transcribing, preparation and administration, as well as dispensing and monitoring.4 Additional events that may lead to medication errors are product labeling, packaging, nomenclature, compounding, distribution, education, and patient use.4 Medication errors can also be caused by workflow issues as well as short staffing. All of these events should be considered by the pharmacist and the entire pharmacy team.
Prescribing errors represent a majority of medication errors.2,8,9 A prescribing error pertains to the choice of a drug, which involves a drug’s indications, contraindications, and the patient’s known allergies.10 A patient’s characteristics must always be considered. Additional factors involve “dose, concentration, drug regimen, pharmaceutical form, route of administration, duration of treatment, and instructions of use.”10 A medication prescription error may also include the failure to prescribe a drug for a patient who needs the treatment for a medical condition or for a patient who needs the drug as a treatment of another drug’s adverse effects.10
Prescribing Potentially Inappropriate Medications in the Elderly
A prescribing error may include prescribing a medication that is potentially inappropriate for a certain patient population, specifically, the elderly.11 In these situations, a medication may have adverse risks that exceed the health benefits to an elderly patient. There may also be safer or equally effective alternative medications that could be prescribed in their place.11
In 1991, Dr. Mark H. Beers developed the Beers Criteria.12 The Beers Criteria provided guidance on the appropriate or inappropriate use of medications in geriatric patients.12 The American Geriatric Society (AGS) is currently responsible for the regular updates of the Beers Criteria.11
The AGS criteria deal with prescribing drugs within the context of “consideration of diagnosis, use of caution, simultaneous prescription of drugs that could interact, and avoidance or reduction of dosage according to individual kidney function.”11 The updated Beers criteria, supported with a discussion of the quality of evidence and strength of each recommendation are available directly from the AGS.13
Drug Not Indicated
A prescribing error includes drugs prescribed for a patient that are not indicated for the patient’s medical condition. One study found that an average of 2.7 medications per patient were not indicated for the patient given the patient’s diagnosis.10
A medication error may result when a drug is contraindicated for a patient with a particular disease.10
A medication error may result when a patient is prescribed multiple drugs that may interact negatively.10
Medication Consideration for Children
The age of a patient should always be verified and considered with prescriptions for children as they require extra caution. Doses for children are often smaller than doses for adults, with some requiring weight-based dosing
for safe administration. Pediatric dosing should always be confirmed prior to processing prescriptions
Transcription errors occur because of poor communication. They typically do not occur because of a lack of knowledge.14 With these errors, an order from a prescriber fails to be properly communicated to the individual dispensing or administering the medication.14
A transcription error may arise with both handwritten and verbal orders.14 Handwritten prescriptions can cause issues if they are illegible.9,10 “The process of transcribing a drug order manually from one sheet to another appears to be a significant source of error.” More than one-half of handwritten prescriptions have been reported to be “poorly readable or unreadable.”10 Orders are more likely to be unclear or misinterpreted when the prescription is given verbally.14 Verbal readback on telephone orders is a way to reduce misinterpreted orders significantly. If a message is left on the answering machine and any part of it is unclear, the pharmacist should call the provider back to verify the information.
Electronic prescriptions have helped in this regard, but they have introduced new issues regarding prescription errors.15 Prescription errors that persist even with electronic prescriptions are “wrong drug, wrong dose, wrong route, wrong duration, and wrong formulation.”2 Drop-down lists can create an issue as it is easy for a provider to pick the wrong drug, dose, or instructions. If any part of an electronic prescription seems odd to the pharmacist, they should verify with the provider that the correct information has been submitted electronically. Pharmacists should always verify the date of birth for the patient on an electronic order, as well as be aware of alternate spellings of names and hyphenated names to ensure that the prescription is being entered under the correct patient. The notes field of an electronic prescription should also be taken into consideration, as some electronic prescriptions indicate dosing changes and request that previous prescriptions are discontinued.
Preparation and Administration Errors
Preparation errors typically occur when a drug is improperly constituted or incorrectly concentrated.2 Administration errors involve mistakes when giving medication to a patient. Examples of administration errors include missed, untimely or incorrect doses, unlicensed staff administering medication, wrong administration technique and rate, double dosing, and the administration of an expired medication or the medication was administered longer than recommended or not long enough.2,16,17
An administration error happens when clinicians fail to document or incorrectly document medication and/or fail to follow medication administration policies.18 Also, questions are being raised about the lack of patient education and informed consent of patients on medication risks and benefits.18
Dispensing and Monitoring Errors
A dispensing error is multifactorial. It can pertain to dispensing medication to the wrong patient, giving the wrong medication to a patient, or giving medication at the wrong time. Pharmacists should never bypass allergy and interaction alerts without further investigation into the patient’s profile. Many dispensing errors can be avoided by preventative measures, including not using abbreviations, awareness of look-alike/sound-alike drugs, and verbal readback and confirmation of prescriptions and allergies when indicated. In a busy retail setting, errors can be reduced with appropriate staffing levels, as when pharmacists are busy or rushing, there are several areas where errors may be more likely to occur. Some examples of errors that occur when pharmacy staff members are rushed include wrong medications in the wrong bottles (especially if multiple medications are being dispensed to the same patient), allergies and interactions being bypassed, and technicians acting outside of their scope of practice. If a prescription comes through on a medication that you are not familiar with, pharmacists should always take the time to do appropriate research on the medication and its uses and contraindications.
The monitoring of medications establishes the effectiveness of treatment and the need to adjust doses.10,18 Medication tolerance is an important part of monitoring treatment and is often a standard requirement of treatment with medications like lithium, warfarin, and cardiac medications.19 Some medications require routine laboratory monitoring of drug levels and the drug’s effect on bodily functions (such as renal function).19
The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that focuses on the prevention of medication errors.20 The ISMP identifies medications that pose a high risk of patient harm or death should a medication error occur.20 These medications are not always associated with more medication errors, but significant harm may be caused if an error occurs with these medications. These medications often require more frequent monitoring before further refills or large day supply quantities are supplied. These drugs are identified and listed as “High-Alert Medications in Acute Care Settings” and may be accessed on the ISMP website.20 Examples of these medications include opioids, oral and injectable antithrombotics, concentrated injectable potassium, magnesium, and hypertonic sodium chloride for injection, pediatric medications, chemotherapy agents, HIV medications, immunosuppressants, and medications contraindicated in pregnancy. 21,22
Root Causes of Medication Errors
Human and systemic factors are root causes of medication errors that include a lack of training or education of providers, unavailability of guidelines for medication administration, fragmentation of medication information, interruption during medication administration, poor communication between providers, and a failure to follow the rights of medication administration.18 Many errors arise because of the time constraints often present when providing healthcare services.23 Each of these can lead to medication errors that increase the risk of harm to patients, may extend a patient’s hospital stay and may result in other negative outcomes.
Lack of Training or Education
Health clinicians are required as professionals to maintain knowledge in their respective areas of practice and to complete continuing education for licensing and professional certification, which is often a requirement of employment.24 The lack of knowledge is a major cause of medication errors.25 Lack of resources and/or time for increasing knowledge has been identified as a significant barrier to safe and appropriate healthcare.24,25 In a pharmacy setting, pharmacists may not receive the proper amount of training due to time constraints and staffing shortages, which can result in errors and stressful environments for staff and patients.
Unavailability of Guidelines for Medication Administration
Guidelines are not always available for the administration of medications.24 For example, a number of medications lack formal approval or dosing information for a specific patient population.26 Off-label uses may result in unguided drug administration that may result in administration errors.26
Prescribing, transcribing, preparing, dispensing, or administering drugs requires a provider’s undivided attention. Interruptions during these events can lead to medication errors.18 Interruptions are common and unfortunately unavoidable in the pharmacy setting. A lack of appropriate staffing can lead to further interruptions as there are not as many people to allocate tasks to. In retail and hospital pharmacy settings, phone calls are a large source of interruptions. In the retail pharmacy setting, you are subject to interruptions by patients who are at the location and are waiting to drop off prescriptions, pick up prescriptions, or require counseling. Although not always favored by patients, it is advisable to indicate that you must finish your current task prior to engaging with them in order to give the prescriptions, as well as the patients, your full attention.
Fragmentation of Medication Information and Poor Communication
The use of multiple medical specialists or medical systems to care for a patient has its benefits, but it can also increase the possibility of a medication error. A patient’s health information does not always follow the patient from one provider, service, or level of care to the next provider, service, or level of care. This is called medical information fragmentation. Furthermore, fragmentation of medication information is implicated in other root causes of medication errors.27 For example, fragmented medication information may result in poor communication.
Communication is important to the delivery of safe and appropriate healthcare services. Communication takes place amongst the different providers who may be involved in a patient’s treatment.27 In many instances, a patient’s care will be transferred from one provider to another. Poor communication inhibits the flow of information to the next provider, service, and level of care. This may cause harmful medication errors.27 Medication reconciliation has become much more common and is discussed below as a strategy to mitigate the fragmentation of medical information.
Poor communication may also result because of the use of non-standard abbreviations or because of sound-alike medications.14 As mentioned above, this may lead to a transcription error.14 The above forms of poor communication create a greater risk that a medication error may occur, which may result in a poor outcome for the patient.27
Failure to Follow the Rights of Medication Administration
The rights of medication administration are patient rights that are required for safe medication ordering and use.18 The rights of medication administration are enumerated and discussed below. At this point, it is important to understand that a healthcare provider who does not utilize or follow these rights is more likely to make a medication error.18
Healthcare may take place at a rapid pace. Each day, healthcare clinicians may see a high volume of patients, and pharmacists may be filling a large number of prescriptions.23 When a pharmacist works under time constraints, the pharmacist is driven or compelled to work quickly, perhaps too quickly. This increases the risk of a medication error.23
Medication Error Reduction Strategies
Several strategies may be implemented by the pharmacy team to reduce medication errors. These strategies include the use of technology and the benefits of continuing education. Pharmacists may also participate in patient education about medications.
Most healthcare facilities are computerized to help make the flow of information and the dispensing and administration of medications timelier and more accurate. Pharmacists should play a role in developing standardized medication use protocols. This may include the pharmacist working actively with healthcare facilities the pharmacist works for to help identify risks of medication errors at the facility and develop strategies to reduce these errors. Forms of active participation by a pharmacist may entail pharmacist-led educational interventions and pharmacist-led reconciliation programs. Pharmacists may also reduce medication errors through continuing education to fill the pharmacist’s knowledge gaps, implementing pharmacy workflow strategies, use of the High-Alert Medications in Acute Care Settings provided by IMSP, and use of the Medication Error Reporting Program (MERP).
A pharmacist may help reduce medication errors by educating patients on medication errors. Patient education should also include a greater role for the pharmacist with a patient’s over-the-counter (OTC) medications. Pharmacy technicians also play a major role in helping the pharmacist reduce errors. Pharmacists should regularly be checking in with their technicians to make sure the workflow is conducive to the environment, as technicians often
have great suggestions and can see some downfalls that a pharmacist may overlook.
Standardized Medication Use Protocols
The American Society of Health-System Pharmacists (ASHP) provides guidelines for the prevention of medication errors.28 These guidelines begin with the recommendation that healthcare facilities do a risk assessment and, from that assessment, prepare a plan to reduce medication errors.28 The ASHP guidelines focus on two factors: the identification of facility-specific, high-alert medications and risk reduction strategies for medication errors.28 A list of high-alert medications may be reviewed from the ISMP list of high-alert drugs. The facility’s medication use patterns and historical adverse events should also be considered.26 Pharmacists who work with a hospital or healthcare facility should take an active role in this process.28
The ISMP has published the Key Elements of Medication Use.29 This document provides important information on the protocols that should be followed when medication is prescribed and administered. This information includes patient and drug information, as well as recommendations regarding the communication of drug information, drug labeling, packaging and nomenclature, and drug storage.29 The ISMP’s full recommendation is available online.29
Computerized systems have been incorporated into the modern healthcare industry. One of the intents of these systems is to help reduce medication errors at various points in the process.14 However, pharmacists should continue to be vigilant when checking electronic prescriptions as errors still occur. Incorrect directions selected by the provider are errors that are frequently reported when using electronic prescribing systems. Other common errors involve the incorrect drug, quantity, and/or strength.30
Computerized Provider Order Entry Systems
Transcription errors occur because of poor communication between the prescriber and the provider who is dispensing or administering the drug. Handwritten errors and unclear or misinterpreted orders often interfere with the proper flow of information. Computerized provider order entry (CPOE) systems were developed to eliminate these errors through direct entry of the prescribing information into the CPOE system.14 Utilizing these systems does help reduce human error that may result from verbal orders or handwritten orders, but problems may persist because of sound-alike medications and abbreviations.14
Automated Dispensing Cabinets
Automated dispensing cabinets (ADCs) are devices that store and dispense medications through a computerized system. These devices offer the pharmacist an opportunity to profile the patient and review medication orders prior to medication administration.14 As with other computer systems, medication errors may still occur without proper attention.14
Barcode Medication Administration Systems
Barcode medication administration systems place an identification number on each medication and patient that is unique to them.14 “This allows for patient, medication, and employee identification codes to be scanned automatically to ensure that the right patient, drug, dose, route, and time are correct prior to administration.”14 Use of this technology has helped reduce administration errors.14
Education to Fill Knowledge Gaps
Pharmacists are sure to have knowledge gaps when it comes to their profession. This is due in part to the fact that knowledge is not static; information changes and grows. Provider education is important in filling knowledge gaps.24,25 Formal education can help narrow these deficits;
however, there may be instances where there is an immediate need for information, and quick-reference guides or brochures can be useful until more formal education can be completed.14 It is truly important to familiarize yourself with any medication that is new to you prior to dispensing to ensure patient safety and quality of care.
Pharmacy Workflow Strategies
Pharmacy workflow strategies should be implemented. This involves reducing office clutter and limiting distractions when preparing prescriptions (e.g., answering questions, receiving or making phone calls, accessing the internet).31 There are systems available that assist pharmacists with patient safety, such as “bar code scanning, drug utilization review for each prescription, a two-step verification process, prescription post fill auditing, and built-in technologies that provide alerts when medication may be incorrect.”31 It is imperative to work as a pharmacy team as sometimes workflow deficiencies can be identified by one person and not another. All members of the pharmacy team should feel valued in suggesting constructive criticism regarding workflow strategies to make for the safest and most pleasant work environment.
Pharmacist-led Educational Interventions
Medication errors may be reduced by pharmacist-led educational interventions directed to healthcare providers.2 Here, the pharmacist takes on the role of educator and provides medication information training. Examples of these educational programs include brochures or training activities presented by a pharmacist that are designed to improve the knowledge and skills of healthcare workers.2 One study reported that a pharmacist-led educational program reduced the risk of a medication error by about 15.8%.16,32 In this study, the pharmacist observed staff members of a provider administering a drug to a patient and then followed the observation with feedback and education regarding observed risks or errors.16,32
Pharmacist-led Medication Reconciliation Programs
Medication reconciliation is a program where a healthcare provider reviews patient files to reconcile drug administration and find drug discrepancies and medication errors.33 Pharmacist-led medication reconciliation may be particularly useful in reducing medication discrepancies when a patient’s care is transitioning from one provider to another. The pharmacist reviews the closed patient file from the prior provider and reconciles any drug discrepancies so they may be resolved and not repeated with the new provider.33,34 This strategy can help avoid medication errors and prevent harm to the patient.33 Another form of medication reconciliation takes place upon arrival to a facility, where a pharmacist or technician may make phone calls to outpatient pharmacies as well as previous and current providers to verify current medications and dosages that the patient is taking.
One drawback of pharmacist-led medication reconciliation is that it may be time-consuming and costly.34 One alternative would be to use computerized medication reconciliation to reduce prescribing errors, but some studies show that computerized medication reconciliation is not as effective as pharmacist-led medication reconciliation in reducing errors.34 Because it is more effective, Manias, et al. (2020) believe that the additional time and cost of pharmacist-led medication reconciliation are worth it.34 Barriers to medication reconciliation include transcription errors, access to the records if the pharmacies are not open, and time constraints.
“Rights” of Medication Administration
The causes of medication errors are complex; however, there are some basic, effective methods to avoid medication errors. One of these methods is the rights of medication administration.18,35
The rights of medication administration vary in the number of rights listed.18,35 The basic list provides “five rights” that are required for safe medication ordering and use. A provider double-checks that the rights of medication administration have been met. The five rights are:35
The drug is being administered to the right patient
The right drug is being administered
The right dose is being administered
The drug is being administered at the right time
The drug is being administered via the right route
This list has been supplemented with additional “rights of medication administration” in order to make it more sensitive and effective at preventing medication errors.35 In some settings, the list has expanded to 6 or even 10 rights.18 For example, Schiff, et al. (2016) stated a sixth right must be added to each prescription: the right indication.36 This sixth right is of particular importance to pharmacists, especially with the computerization of medical records. Schiff, et al., pointed out that with the addition of an “indications- based computer prescribing system,” pharmacists could more easily catch drug–indication mismatches.36
The list of rights of medication administration is a useful tool, but it should not be viewed as sufficient by itself to address medication errors. Attention to the root causes of medication errors that are systemic should be continued, and improvements should regularly be made.35 In addition, cognitive and physical factors are not always solved with lists, especially in a fast-paced work environment.35 Systems that have a pharmacist check orders at multiple stages of input and dispensing help to catch all the rights of medication administration.
High-Alert Medications in Acute Care Settings
As mentioned above, the ISMP has identified medications that pose a high risk of patient harm or death if a medication error occurs.20 This list is entitled High-Alert Medications in Acute Care Settings.20 This list was last updated in 2018.20
High-Alert drugs must be understood in the context of drug use. Drugs are prescribed to prevent or treat an illness and often provide a measurable effect. In order to avoid medication errors, clinicians should be aware of look-
alike and sound-alike drugs and drug abbreviations. A significant number of medication errors that occur in the United States involve name confusion, and these errors have the potential to cause great harm.
Awareness of Error-Prone Abbreviations
Regarding the proper use of abbreviations, each healthcare facility should have a list of acceptable abbreviations, and clinicians should know where the list is and what it contains. The ISMP provides a List of Error-Prone Abbreviations on its website.37 Commonly used abbreviations related to medication administration that can be used mistakenly or misidentified are ones, such as U (or u) intended to mean unit but easily mistaken for a 0 or 4, SC intended to mean subcutaneous but easily mistaken for SL (sublingual), and QOD intended to mean every other day but easily mistaken as QD (every day) if it is written illegibly.37 Although some prescribers still use abbreviations for drug names (e.g., MTX for methotrexate), they are not safe, and the order should be verified with the prescriber prior to dispensing.
Medication Errors Reporting Program (MERP)
The Medication Errors Reporting Program (MERP) is a program provided by the United States Pharmacopeia (USP) and the Institute of Safe Medication Practices (ISMP). The MERP is a nationwide reporting system for actual or potential medication errors.38 The MERP includes reports of drug misinterpretations, miscalculations, misadministration, illegible handwritten orders, or misunderstood verbal orders.38 These reports are reviewed by the USP, and the information is sent to the FDA and to the drug or product manufacturer.38 This provides an additional resource to providers to make them aware of actual or potential medication errors. Utilization of resources such as MERP can help reduce or prevent medication errors.
Patients must be educated about the medications they are prescribed. This is usually conducted by pharmacists when patients are picking up a
prescription from a community pharmacy, or a pharmacist may counsel a patient on medications prior to being discharged from a facility setting.28,29,34 This education should include “the brand and generic names of medications they are receiving, their indications, usual and actual doses, expected and possible adverse effects, drug or food interactions, and how to protect themselves from errors.”29 With education, a patient can play a vital role in preventing medication errors.29 Medication errors can be identified during patient education and counseling. Sometimes when going over a medication with the patient, the indication, dosage, or even name of the medication may alert a patient to a potential medication error if the information does not match what the provider told them initially. A pharmacist can then follow up with the provider to ensure the accuracy of the original prescription.
According to the FDA, patients, as consumers, should be educated by their physician or pharmacist on the following safety tips and questions. Consumers should ask their pharmacist if any of the following is unclear to them:3
Know the various risks and causes for medication errors.
Know the drug you are prescribed and what it is for. Ask your prescriber for the name of the drug and the purpose of the drug.
Find out how to take the drug and make sure you understand the directions. Ask if the medication needs to be kept in the refrigerator.
Check the container's label every time you take a drug. This is especially important if you are taking several drugs because it will lower your risk of accidentally taking the wrong medication.
Keep medications stored in their original containers. Many tablets/capsules look alike, so keeping them in their original containers will help the patient know the name of the drug and how to take them. If you are having trouble keeping multiple medications straight, ask your doctor or pharmacist about helpful aids.
Keep an updated list of all medications taken for health reasons, including OTC drugs, supplements, medicinal herbs, and other substances. Give an updated copy of this list to your healthcare provider regularly.
Be aware of the risk of drug-drug and food-drug interactions.
If you are in doubt or if you have questions about your medication, ask your pharmacist.
Report suspected medication errors to MedWatch (the FDA’s “Safety Information and Adverse Event Reporting Program”).
Pharmacist Involvement with Over-the-counter (OTC) Medications
In the U.S., OTC medications are available to people without a prescription.39 This poses a significant risk of drug interactions and medication errors that may lead to harm, especially in pediatric and elderly patients.39 The extent of this issue is great. An estimated one-third of older adults reportedly use OTC drugs, and this percentage increases to one-half with people 75 to 85 years of age.39 Some older adults use two or more OTC drugs.39 Gilson, et al. (2021) believe that “over one million older adults are in physical jeopardy from harms related to the use of 2 or more OTC medications.”39
Of the ten drugs most frequently used by the public, four of them are available OTC.40 These four OTC drugs are ibuprofen, aspirin, acetaminophen, and diphenhydramine.40 These drugs are also available in multiple-ingredient preparations, which increases the risk of a potentially dangerous overdose.40 To address this serious problem, pharmacy aisles may be redesigned, and pharmacists can become more interactive with older adults or parents of young children when it comes to OTC drug purchases.39-41 The redesign of store aisles and greater interaction with pharmacy staff are intended to decrease the potential misuse of these drugs and provide patients with more information and awareness about the possible dangers of OTC medication. Pharmacy staff members are able to observe individuals when they are purchasing OTC drugs and then engage in conversations with them and make recommendations.40
Reporting Medication Errors
Under federal law, there are voluntary reporting systems for medication errors. For example, the FDA receives voluntary reports at the FDA Adverse Event Reporting System (FAERS).42 The Medication Errors Reporting Program discussed above is another program for reporting medication errors.38
Some states mandate reporting of certain medication errors, and most hospitals and healthcare facilities have policies that indicate the processes their pharmacists should follow when a medication error occurs.43 If a healthcare professional is required to report a medication error under state law, the error must be documented, and the healthcare professional must investigate what occurred.44
A pharmacist may consult with a legal advisor, or if employed, with the pharmacist’s employer or supervisor to determine their obligation to report a medication error under an employer’s policies or under the state law in which the pharmacist is licensed.
Medication errors should be reported and evaluated to help the healthcare facility and the professional implement prevention strategies. The medication error reduction strategies, discussed above, such as education and training, and changes in policies, may then be used to prevent future occurrences. Scholars argue that clinicians should work in an environment where they feel confident identifying and reporting errors without fear of punishment.44,45
There are also cases where a patient reports a medication error, and a healthcare facility or pharmacy must respond to the report. This usually occurs in the context of a patient who has been injured by a medication error.46,47 The healthcare facility or pharmacy should have policies in place in advance of such events, and all staff should be well trained in the processes for responding to a report of a medication error.46,47 The ISMP recommends that the policies include a conversation with the patient, and possibly the patient’s family or caregiver, when appropriate, to discuss the error. The ISMP strongly
suggests that follow-up with the patient include an apology when necessary. This approach is considered better than taking a defensive approach and denying any wrongdoing. Again, a pharmacist who is employed by a hospital or pharmacy should consult with the pharmacist’s employer or supervisor before making a report or conversing with a patient, to ensure that policies and procedures are followed.46,47
Disclosing Medication Errors to the Patient
When a medication error does occur, the question arises when must or should a pharmacist disclose the error to the patient. Most states require that the patient be notified of an error.44 Pharmacists who work within a hospital setting report that the number of weekly medication errors is significantly higher in that setting.43 Most pharmacists work in a hospital setting with mandatory error reporting, but significantly less than half have a policy on error disclosure to the patient.43 This may be due to the different reporting rules or policies that hospitals have implemented, namely, who is responsible for disclosure to the patient. According to Mazan, et al. (2020), most hospital pharmacists believe that they are not responsible for disclosing a medication error.43 Pharmacists outside the hospital setting reported a “higher awareness of guidelines on disclosure to patients, as they are more likely to be involved in the process.”43
Mazan, et al., propose that medication errors should be disclosed to the patient and to family members when appropriate. While this may be difficult to do, it is “vital for the patient’s physical and emotional wellbeing [and] the wellbeing of healthcare systems, as acknowledging errors is the first step in correcting them.”43 A pharmacist should consult with their employer, supervisor, or legal advisor to determine their obligation to report a medication error to the patient.
A medication error has been identified by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) as a
preventable event involving inappropriate medication use and potentially may result in patient harm and an adverse drug event. The failure to communicate drug orders and illegible writing are amongst the more common failures related to medication errors. Name confusion over similarly named drugs or errors involving dosing units are also common reasons medication errors can occur. Medication errors can be due to human errors; however, more typically, a medication error results from a systemic failure, such as the fragmentation of medication information as a patient moves between providers, services, and levels of care.
Strategies that may be implemented by a pharmacist to reduce medication errors may include the pharmacist working actively with healthcare facilities to help them identify risks of medication errors at the facility and developing strategies to reduce these errors. This may include pharmacist-led educational interventions and pharmacist-led medication reconciliation programs, which may help reduce medication errors. Pharmacists are an integral part of the healthcare team, and by working together with open communication on all fronts, medication errors can be greatly reduced or avoided.
A medication error is best defined as an event that
causes patient harm.
is preventable and may cause harm.
is caused by a healthcare provider, not a patient.
must be disclosed to the patient and the patient’s family.
A majority of medication errors are caused by
the use of over-the-counter medications.
by the manufacturer’s erroneous product labeling or packaging.
A medication error that results in harm to a patient is called
an adverse drug event.
a near miss.
a monitoring error.
The list of “High-Alert Medications in Acute Care Settings” identifies drugs that
carry a higher risk of harm when a medication error occurs.
are more prone to medication errors.
have the potential for medication errors.
have actually caused medication errors.
One of the root causes of medication errors is the fragmentation of medication information that arises when a patient’s medication information
is mixed with another patient’s medication information.
is not given to the patient.
does not follow the patient from one provider, service, or level of care to another.
True or False: A prescribing error may include prescribing a medication that is potentially inappropriate for an elderly adult.
One strategy to reduce medication errors is a pharmacist-led medication reconciliation program in which the pharmacist
sits down with the patient and discloses medication errors.
trains healthcare staff on medication errors.
reviews closed patient files to find drug use discrepancies.
reviews a patient’s medication bills for errors.
typically occur when a drug is improperly constituted or incorrectly concentrated.
Incorrect drug indications
Examples of include missed, untimely or incorrect medication doses.
If a patient reports a medication error and the pharmacy must respond, the ISMP states that the best approach is
to not say anything because of the potential liability if there was an injury.
to have a conversation with the patient and possibly the patient’s family or caregiver, when appropriate, to discuss the error.
to deny any wrongdoing.
to not respond because these complaints usually go away on their own.
Barcode medication administration systems place an identification number on each
medication error so it may be tracked.
medication and patient that is unique to them.
prescription and any transcription to make sure they match.
over-the-counter drug purchase.
The sixth right in the list of rights of medication administration - the Right Indication - is of particular importance to pharmacists because it can help them
more easily catch drug–indication mismatches.
know if the drug dose was indicated correctly on the prescription.
identify the correct route of administration.
Pharmacy aisles may be redesigned, and pharmacists can become more interactive with patients when it comes to
the proper use of medication abbreviations.
the use of computer systems such as CPOE systems.
pharmacist-led educational interventions.
over-the-counter drug purchases.
Barriers to medication reconciliation include
access to records
All of the above
True or False: Four over-the-counter drugs are among the top 10 drugs most frequently used by the public, and they are ibuprofen, aspirin, acetaminophen, and diphenhydramine.
Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000.
Jaam M, Naseralallah LM, Hussain TA, Pawluk SA. Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: A systematic review and meta-analysis. PLoS One. 2021 Jun 23;16(6):e0253588. doi: 10.1371/journal.pone.0253588. PMID: 34161388.
Food and Drug Administration. Working to reduce medication errors. https://www.fda.gov/drugs/drug-information-consumers/working- reduce-medication-errors. Accessed June 23, 2021.
National Coordinating Council for Medication Error Reporting and Preventing About Medication Errors. About Medication Errors. What is a Medication Error? 2021. http://www.nccmerp.org/about-medication- errors. Accessed June 23, 2021.
Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995 Apr;10(4):199-205. doi: 10.1007/BF02600255. PMID: 7790981.
Falconer N, Barras M, Cottrell N. Systematic review of predictive risk models for adverse drug events in hospitalized patients. Br J Clin Pharmacol. 2018;84(5):846-864. doi:10.1111/bcp.13514
Insani WN, Whittlesea C, Alwafi H, Man KKC, Chapman S, Wei L. Prevalence of adverse drug reactions in the primary care setting: A systematic review and meta-analysis. PLoS One. 2021;16(5):e0252161. Published 2021 May 26. doi:10.1371/journal.pone.0252161
Velo GP, Minuz P. Medication errors: prescribing faults and prescription errors. Br J Clin Pharmacol. 2009;67(6):624-628. doi:10.1111/j.1365- 2125.2009.03425.x
Hartel MJ, Staub LP, Röder C, Eggli S. High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process. BMC Health Serv Res. 2011;11:199. Published 2011 Aug 18. doi:10.1186/1472-6963-11-199
Assiri GA, Shebl NA, Mahmoud MA, et al. What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature [published correction appears in BMJ Open. 2019 May 27;9(5):e019101corr1]. BMJ Open.
2018;8(5):e019101. Published 2018 May 5. doi:10.1136/bmjopen-
Sharma R, Bansal P, Garg R, Ranjan R, Kumar R, Arora M. Prevalence
of potentially inappropriate medication and its correlates in elderly hospitalized patients: A cross-sectional study based on Beers criteria. J Family Community Med. 2020;27(3):200-207. doi:10.4103/jfcm.JFCM_175_20
Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med. 1991 Sep;151(9):1825-32. PMID: 1888249.
By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019 Apr;67(4):674-694. doi: 10.1111/jgs.15767. Epub 2019 Jan 29. PMID: 30693946.
Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med. 2014;6:45-55. Published 2014 Jul 23. doi:10.2147/OAEM.S64174
Palchuk MB, Fang EA, Cygielnik JM, et al. An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies. J Am Med Inform Assoc. 2010;17(4):472-476. doi:10.1136/jamia.2010.003335
Koeck JA, Young NJ, Kontny U, Orlikowsky T, Bassler D, Eisert A. Interventions to Reduce Medication Dispensing, Administration, and Monitoring Errors in Pediatric Professional Healthcare Settings: A Systematic Review. Front Pediatr. 2021;9:633064. Published 2021 May
Dhawan I, Tewari A, Sehgal S, Sinha AC. Medication errors in anesthesia: unacceptable or unavoidable? Braz J Anesthesiol. 2017 Mar- Apr;67(2):184-192. doi: 10.1016/j.bjane.2015.09.006. Epub 2016 May
Tsegaye D, Alem G, Tessema Z, Alebachew W. Medication Administration Errors and Associated Factors Among Nurses. Int J Gen Med. 2020;13:1621-1632. Published 2020 Dec 22. doi:10.2147/IJGM.S289452
Härkänen M, Paananen J, Murrells T, Rafferty AM, Franklin BD. Identifying risks areas related to medication administrations - text mining analysis using free-text descriptions of incident reports. BMC Health Serv Res. 2019;19(1):791. Published 2019 Nov 4. doi:10.1186/s12913-019-4597-9
Institute for Safe Medication Practices. High-Alert Medications in Acute Care Settings. ISMP. August 23, 2018. https://www.ismp.org/recommendations/high-alert-medications-acute- list. Accessed June 25, 2021.
list. Accessed July 13, 2022.
medications-community-ambulatorylist. Accessed July 13, 2022.
Shao SC, Chan YY, Lin SJ, et al. Workload of pharmacists and the performance of pharmacy services. PLoS One. 2020;15(4):e0231482. Published 2020 Apr 21. doi:10.1371/journal.pone.0231482
Frenzel JE, Skoy ET, Eukel HN. Use of Simulations to Improve Pharmacy Students' Knowledge, Skills, and Attitudes About Medication Errors and Patient Safety. Am J Pharm Educ. 2018;82(8):6644. doi:10.5688/ajpe6644
Escrivá Gracia J, Brage Serrano R, Fernández Garrido J. Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. BMC Health Serv Res. 2019;19(1):640. Published 2019 Sep 6. doi:10.1186/s12913-019-4481-7
Tolley CL, Forde NE, Coffey KL, et al. Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review. J Am Med Inform Assoc. 2018;25(5):575-584. doi:10.1093/jamia/ocx124
Manskow US, Kristiansen TT. Challenges Faced by Health Professionals in Obtaining Correct Medication Information in the Absence of a Shared Digital Medication List. Pharmacy (Basel). 2021;9(1):46. Published 2021 Feb 22. doi:10.3390/pharmacy9010046
Billstein-Leber M, Carrillo CJD, Cassano AT, Moline K, Robertson JJ. ASHP Guidelines on Preventing Medication Errors in Hospitals. Am J Health Syst Pharm. 2018 Oct 1;75(19):1493-1517. doi: 10.2146/ajhp170811. PMID: 30257844.
Institute for Safe Medication Practices. Key Elements of Medication Use. ISMP. Undated. https://www.ismp.org/key-elements-medication-use. Accessed August 25, 2022.
Hincapie AL, Alamer A, Sears J, Warholak TL, Goins S, Weinstein SD. A Quantitative and Qualitative Analysis of Electronic Prescribing Incidents Reported by Community Pharmacists. Appl Clin Inform. 2019;10(3):387-394. doi:10.1055/s-0039-1691840
Grant M, Remines J, Nadpara P, Goode JKR. Impact of Live Training on Medication Errors in a Community-Based Pharmacy Setting. Innov Pharm. 2020;11(3):10.24926/iip.v11i3.3291. Published 2020 Jul 31. doi:10.24926/iip.v11i3.3291
Chua SS, Choo SM, Sulaiman CZ, Omar A, Thong MK. Effects of sharing information on drug administration errors in pediatric wards: a pre-post intervention study. Ther Clin Risk Manag. 2017;13:345-353. Published 2017 Mar 23. doi:10.2147/TCRM.S128504
Mekonnen AB, McLachlan AJ, Brien JA. Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital
transitions: a systematic review and meta-analysis. BMJ Open.
2016;6(2):e010003. Published 2016 Feb 23. doi:10.1136/bmjopen-
Manias E, Kusljic S, Wu A. Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Ther Adv Drug Saf. 2020;11:2042098620968309. Published 2020 Nov 12. doi:10.1177/2042098620968309
Misasi P, Keebler JR. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. Ther Adv Drug Saf. 2019;10:2042098618821916. Published 2019 Jan
Schiff GD, Seoane-Vazquez E, Wright A. Incorporating Indications into Medication Ordering--Time to Enter the Age of Reason. N Engl J Med. 2016 Jul 28;375(4):306-9. doi: 10.1056/NEJMp1603964. PMID:
Institute for Safe Medication Practices. List of Error-Prone Abbreviations. ISMP. February 5, 2021. https://www.ismp.org/recommendations/high-alert-medications-acute- list. Accessed June 26, 2021.
Patel I, Balkrishnan R. Medication Error Management around the Globe: An Overview. Indian J Pharm Sci. 2010;72(5):539-545. doi:10.4103/0250-474X.78518
Gilson AM, Xiong KZ, Stone JA, Jacobson N, Chui MA. A pharmacy- based intervention to improve safe over-the-counter medication use in older adults. Res Social Adm Pharm. 2021;17(3):578-587. doi:10.1016/j.sapharm.2020.05.008
Chui MA, Stone JA, Holden RJ. Improving over-the-counter medication safety for older adults: A study protocol for a demonstration and dissemination study. Res Social Adm Pharm. 2017;13(5):930-937. doi:10.1016/j.sapharm.2016.11.006
Gilson AM, Xiong KZ, Stone JA, et al. Improving Patient-Pharmacist Encounters with Over-The-Counter Medications: A Mixed-Methods Pilot Study. Innov Pharm. 2020;11(1):10.24926/iip.v11i1.2295. Published 2020 Feb 14. doi:10.24926/iip.v11i1.2295
Zhou S, Kang H, Yao B, Gong Y. Analyzing Medication Error Reports in Clinical Settings: An Automated Pipeline Approach. AMIA Annu Symp Proc. 2018;2018:1611-1620. Published 2018 Dec 5.
Mazan JL, Lee MK, Quiñones-Boex AC. American Pharmacists Attitudes and Behaviors Regarding Medication Error Disclosure. Innov Pharm. 2020;11(4):10.24926/iip.v11i4.3373. Published 2020 Dec 15.
Marcoux RM, Vogenberg FR. Professional Roles Evolve With Changing Landscape of Legal Risk. P T. 2015;40(9):579-582.
Rogers E, Griffin E, Carnie W, Melucci J, Weber RJ. A Just Culture
Approach to Managing Medication Errors. Hosp Pharm. 2017;52(4):308-
Institute for Safe Medication Practices. ISMP. Respond to consumers’ error concerns with empathy and honesty. Board of Pharmacy News. Vol. XVII, Issue 2. Maryland Board of Pharmacy. 2022. https://content.govdelivery.com/attachments/MDDHMH/2022/08/11/fil e_attachments/2242029/2022%20Summer%20Newsletter%20final.pdf. Accessed September 9, 2022.
Institute for Safe Medication Practices. ISMP. 2021. https://www.ismp.org/resources/excuse-me-i-think-there-error-my- prescription-practitioners-should-respond-empathy-and. Accessed September 9, 2022.
The information provided in this course is general in nature and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.
Healthcare professionals, including pharmacists and pharmacy technicians, must consult with their employer, healthcare facility, hospital, or other organization, for guidelines, protocols, and procedures they are to follow. The information provided in this course does not replace those guidelines, protocols, and procedures but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.
Participants are advised and acknowledge that information related to medications, their administration, dosing, contraindications, adverse reactions, interactions, warnings, precautions, or accepted uses are constantly changing, and any person taking this course understands that such person must make an independent review of medication information prior to any patient assessment, diagnosis, treatment and/or health management. Any discussion of off-label use of any medication, device, or procedure is informational only and such uses are not endorsed hereby.
Nothing contained in this course represents the opinions, views, judgments, or conclusions of RxCe.com LLC. RxCe.com LLC is not liable or responsible to any person for any inaccuracy, error, or omission with respect to this course, or course material.