Medication Errors: An Overview

Summary

  • Pharmacy medication errors affect over one million Americans each year with costs adding up to almost $77 billion per year.
  • In this blog, we’ll look at the types of medication errors, causes of errors, patient-related risks, and strategies to prevent errors. 

Introduction

Over 1 million Americans are hurt by medication errors every year. The consequences of these errors can be severe and, in some cases, can even be life-threatening. Both healthcare professionals and patients can be involved in making errors.

Morbidity and mortality costs from medication errors add up to about $77 billion a year. And the financial cost of handling drug-related injuries in just hospitals is about $3.5 billion a year.

Medication errors can come in various types:

  1. Giving a drug to the wrong person
  2. Giving the wrong dose
  3. Not prescribing a medication that was needed
  4. Entering an order for the wrong person
  5. Forgetting to give a medication that was due to be given

How medication errors occur

On the healthcare professional side, there are various reasons why medication errors occur and various times in the chain when they occur. Times when errors can happen are during:

  1. Ordering/prescribing
  2. Documenting
  3. Transcribing
  4. Dispensing
  5. Administering
  6. Monitoring

About half of medication errors happen during the ordering/prescribing phase.

Human error is a common reason for medication errors. Human error for healthcare professionals can be caused by large workloads, fatigue, time pressure, a high number of patients, environmental conditions, and interruptions. Communication issues can also be a factor. These can include lack of clarity in verbal orders, delays in passing along information, illegible handwriting, and lack of clear instructions, among others.

Complicated medication regimens can raise the risk of errors for patients who take medicines. People who take multiple medications can take too much or not enough medicine, take the medicine at the wrong time, take medicine without food when it should be taken with food (or vice versa), be unaware of drug interactions, and store drugs improperly. Patients can also mix up pills, be confused by labels, and use expired medications.

How to reduce medication errors

To reduce medication errors, there needs to be a combination of system improvements, use of technology, education, and patient involvement. Some of these include:

  1. Standardizing prescribing and dispensing, using protocols and checklists.
  2. Using clear labels and avoiding abbreviations on pill bottles.
  3. Maintaining electronic health records.
  4. Reconciling medications during transfers of care.
  5. Providing ongoing training to healthcare staff.
  6. Teaching patients about their medications.
  7. Using unit dose packaging.
  8. Implementing clinical decision support systems.
  9. Requiring special safeguards for high-risk medications and/or high-risk patients.

Final thoughts

Medication errors are a significant problem in the U.S. But they can be prevented by building safer systems, implementing technology when needed, better educating both healthcare professionals and patients, clarifying labels and related information, and improving overall communication.

References

Vivian, Jesse C. Medication Errors and Liability Issues. U.S. Pharmacist. September 18, 2024.

Medication Errors. Academy of Managed Care Pharmacy.

Tariq, Rayhan A., Vashisht, Rishik, Sinha, Ankur, and Scherbak, Yevgeniya. Medication Dispensing Errors and Prevention. February 12, 2024.

Wittich, Christopher M., Burkle, Christopher M. , and Lanier, William L. Medication Errors: An Overview for Clinicians. Mayo Clinic Proceedings. Vol. 89, Issue 8. August 2014.

Sameera, Vattipalli, Bindra, Ashish, and Rath, Girja P. Human errors and their prevention in healthcare. Journal of Anaesthesiology Clinical Pharmacology. July-September 2021.

Medication Without Harm. World Health Organization.

The Silent Missteps in Medicine: Unveiling the Impact of Clinical Communication Errors. Backline by DrFirst.

Branch, Jennifer, Hiner, Dakota, and Jackson, Victoria. The Impact of Communication on Medication Errors. PSNet. March 15, 2021.

Crouch, Michelle. 11 Medicine Mistakes to Avoid. AARP. August 6, 2024.

Reducing Medication Errors for Healthcare Providers. Medical Packaging.

Sharma, L alit, Prakash, Ajay, and Medhi, Bikash. Ensuring medication and patient safety for better quality healthcare. Indian Journal of Pharmacology. November-December 2024.

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