Medicines are the most common therapeutic intervention in healthcare and have become much more complex. While patients benefit significantly by living longer and enjoying better quality of life, many experience serious harm due to mistakes or errors in medication use.
What are medication errors?
A medication error is defined as ‘Any preventable event that causes or leads to inappropriate medication use or patient harm while the medication is under the control of a health professional, patient or consumer.’
Medication errors occur often in health systems around the world, and, according to the World Health Organization (WHO), nearly 50% of preventable harm to patients globally is due to inappropriate use of medicines and other treatments. A quarter of this preventable harm can be severe or even life-threatening.
Medication errors occur when weak medication systems or human factors affect processes. As a leading cause of avoidable patient harm, a recent study estimated that there are 237 million medication errors in England every year. The majority are thought to have little or no potential for harm but 66 million of these (28%) are potentially significant.
A European collaboration, European Collaborative Action on Medication Errors and Traceability (ECAMET), aimed at reducing medication errors in hospitals, cited a Spanish study attributing over a third of all adverse events in hospital patients over five years to medication errors. It is uncertain how many medication errors cause or contribute to patient deaths but a small proportion do have a fatal outcome.
Even when errors are not harmful or severe, they can drive the cost of care up, and the quality of care down. Health professionals do their best to protect patients from harm due to medicines but human factors, such as fatigue and insufficient staffing levels, can play a part. Medication errors that lead to patient harm can negatively impact the mental health of health professionals, and their ability to do their job.
Fortunately, with greater awareness of the scale of the problem, there is now a focus on ensuring a culture of safety in health systems. With the right education, policies, prescribing tools, and reporting and learning systems, errors can be minimised and patients protected.
What are the most common types of medication errors?
Medication errors can occur at any stage in the medicine use process. Most studies refer to five main types of error, namely those related to prescribing, transcribing, preparation or dispensing, administration, or monitoring. Aronson also noted that errors can occur during the medicine manufacturing process, for example when the packaging is incorrectly labelled or adulterants are introduced.
It is challenging to identify and quantify the most common types of medication errors, as research evidence is limited, and many go unnoticed or unreported. However, the literature suggests that prescribing, administration, and monitoring errors are the most frequent. The previously mentioned study on the economic burden of medication errors in England suggested that 54% of errors are made at the point of administration, and 21% during prescribing. These figures, the authors explained, are similar to those reported in the USA and European Union countries.
Administration errors
Administration errors may include using the incorrect route of administration, giving the drug to the wrong patient, or using the wrong dose or administration rate. The worldwide prevalence of administration errors is around 22%, according to a WHO systematic review.
Case study: In 2016 a 50-year-old woman complained of chest tightness, breathing difficulties, and tremors during a colonoscopy at an Egyptian hospital. Health professionals found she had accidentally received adrenaline (epinephrine) instead of midazolam. A root cause analysis found that ampules of adrenaline and midazolam – which were similar in size, shape, and colour – had mistakenly been placed in the same box by pharmacy staff.
Medication errors resulting in claims are likely to represent the tip of the iceberg. Their analysis of medication error claims over five years (April 2015 – March 2020) found that of 487 claims settled with damages paid, 45% were related to administration errors. In 27% of these cases, the wrong dose was given, in 18%, the wrong drug was given, and in 15%, the wrong route of administration was used. The most common medications implicated in these claims were; anticoagulants, antimicrobials, opioids, anticonvulsants, and antidepressants.
Prescribing errors
Prescribing errors account for a high proportion of all medication errors, with the World Health Organization suggesting the error rate may be as high as 53%. These errors can happen at any part of the prescribing process and include irrational, inappropriate or ineffective prescribing, under and over-prescribing, and medicines that are omitted or delayed.
Case study: Anti-infectives (NHS Resolution, 2022, anti-infectives). NHS Resolution received 172 claims relating to errors with the prescription of antibiotics, antivirals, and antifungals between April 2015 and March 2020.
The key causes of the claims were:
- Failure to check allergy status
- Failure to cross-check medication ingredients with allergy status
- Failure to adjust the dose to patient’s weight
- Failure to adjust dose according to patient’s renal function.
- The resulting outcomes included anaphylaxis, unnecessary pain, acute kidney injury, and death.
Preventing medication errors
Medication errors are a multifaceted problem. Preventable errors can occur for any number of reasons, from illegible prescriptions, incomplete patient records regarding information on co-prescribed medications, previous response to therapy, and allergy status, to incorrect drug or dose selection and drugs with similar looking or sounding names. With so many contributing factors, there is no one-size-fits-all solution. Rather, tailored approaches to understanding and mitigating the risks are needed. Improved systems can help reduce error rates, such as electronic prescribing and automated dispensing.
Reporting all drug errors and near misses, regardless of whether the patient came to harm, and having processes to investigate and analyse the data is crucial. It is only by building the baseline evidence that health systems can better understand how errors occur, and how to prevent them.
“Use of medicines has increased because of increased adherence to disease-based guidance. The increase in use also results, however, in increased hazards, errors, and adverse events associated with medicines, which can be reduced or even prevented by improving the systems and practice of medication,” WHO, Medication Without Harm, 2023.
A culture of safety in the health system is necessary to ensure medication safety. With the necessary education, support, and tools, individual health professionals can do much to ensure safe practice.
The “5 Rights” of medication safety can help health professionals who administer drugs avoid errors.
Best practice dictates that nurses and others carry out the following checks before giving medication:
- Right patient: Check the patient’s name using two identifiers (e.g. wristband, prescription) and the patient to identify themself if he or she is able.
- Right drug: Check the medication label against what has been prescribed.
- Right dose: Confirm the dose using current references, such as local protocols or British National Formulary (BNF). If necessary, recalculate the dose and have a colleague check it.
- Right route: Check the appropriateness of the route that has been prescribed and confirm with the patient if they can take the medicine that way. For example, can they swallow a tablet or capsule?
- Right time: Check the frequency of the prescribed medication and confirm when the last dose was given.
Other strategies for avoiding administration errors include:
- Following medication reconciliation procedures
- Double or triple-checking procedures
- Having a colleague read the prescription back
- Using name alert systems, which alert health professionals to patients with similar names
- Always placing a zero before decimal points to avoid confusion at the point of administration
- Learning the institution’s medication administration policies, regulations, and guidelines
- Documenting the date, time, route, and dosage of the drug.
Both the General Medical Council (GMC, 2021)¹⁶and the Royal Pharmaceutical Society (RPS Competency Framework, 2021)¹ stipulate that health professionals should make use of all available evidence-based resources to keep their knowledge and skills up to date.
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In the UK, such resources include those published by the Medicines and Healthcare products Regulatory Agency (MHRA), the National Institute for Health and Care Excellence (NICE), BNF, and BNF for Children, all of which are essential for practice.
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