By: Dr.

Ankit Gaur
(B.Pharm, M.Sc, Pharm.D, RPh)
"A medication error is 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. Such
events may be related to professional
practice, health care products, procedures,
and systems, including prescribing; order
communication; product labeling, packaging,
and nomenclature; compounding; dispensing;
distribution; administration; education;
monitoring; and use."
Near Miss (Medication Error): Medication error
that took place but captured before reaching
to the patient. Such events have also been
termed as ‘near miss’ Medication error.

• Human-related
• System-related
• Medication-related
Providers Patients
 Over-worked  In a hurry
 Under-trained  Health literacy
 Competence level
 Distracted  Do not understand

 Illness
the
medication/use
 Stressed
 Trust providers to
not make mistakes
 Lack of communication
 Poor workflow
 Disorganized workspace
 Inadequate tools to complete work
 Lack of supervision
 Look-alike/sound-alike medications
 Multiple dosage forms and strengths
• Right Drug

• Right Route

• Right Time

• Right Dose

• Right Patient

• Right Dosage Form

World Health Organization WHO, Patient Safety Curriculum Guide

Medication errors include
 Prescribing Error
 Dispensing Error
 Documentation Error
 Administration Error
 Transcription Error
 Indent Error
 Prescribing error: A clinically meaningful
prescribing error occurs when, as a result of a
prescribing decision or prescription writing
process, there is an unintentional significant (1)
reduction in the probability of treatment being
timely and effective or (2) increase in the risk
of harm when compared with generally
accepted practice” .
It includes:
 Incorrect Prescription
 Illegible Handwriting
 Drug allergy not identified
 Irrational combinations
 Out of list abbreviations
A dispensing error is a discrepancy between
a prescription and the medicine that the
pharmacy delivers to the patient or
distributes to the ward on the basis of this
prescription, including the dispensing of a
medicine with inferior pharmaceutical or
informational quality
 98.3% accuracy in dispensing medications
 Therefore, 1.7% inaccuracy rate
 Over 3 billion medications dispensed per year
 4 errors per day per 250 prescriptions filled
 Over 51 million dispensing errors per year

Flynn E, et al. J Am Pharm Assoc. 2003;43:191–200.

 Dispensing incorrect medication, dosage
strength, or dosage form
 Dosage miscalculations
 Failure to identify drug interactions or
contraindications
Sound alike and look alike drug names

Generic name Trade name

Clonidin Catapresan
Clomipramin Anafranil
Codein Codein Knoll
Etodolac Lodin
Cotrimazol Bactrim, Cotrim, Nopil
Clotrimazol Canesten, Corisol

http://www.patientensicherheit.ch/de/publikationen/Quick-Alerts.html
 Failure to counsel the patient
 Failure to screen for interactions and
contraindications
 Miscalculation of a dose
 Dispensing the incorrect medication,
dosage strength, or dosage form
 Work environment
 Workload
 Distractions
 Work area
 Use of outdated or incorrect
references
 LASA drugs (Look Alike Sound Alike)
A physician writes an order for primidone
(Mysoline) for a 12-year old boy with a
seizure disorder. Misreading the physician’s
handwriting, the pharmacist mistakenly fills
the order with prednisone. For 4 months, the
boy receives prednisone along with his
seizure medications, causing steroid-induced
diabetes. The diabetes goes unrecognized,
and he dies from diabetic
ketoacidosis…because the drug was LASA
drug that lead to Dispensing Error
Ambiguity in Written Orders
A drug administration error may be defined
as a discrepancy between the drug therapy
received by the patient and the drug therapy
intended by the prescriber.
 Administration errors account for 26% to 32%
of total medication errors.
 It involved wrong patient, wrong route of
administration, wrong drug, wrong dose,
wrong method, wrong time.
 Lack of perceived risk
 Lack of available technology
 Lack of knowledge of the preparation or
administration procedures Complex design of
equipment.
 CONTRIBUTING FACTORS TO DRUG
ADMINISTRATION ERRORS: Failure to check
the patient’s identity prior to administration
Environmental factors such a noise,
interruptions ,poor lighting Wrong calculation
to determine the correct dose
 A critical care nurse tries to catch up with her
morning medications after her patient’s
condition changes and he requires several
procedures. He is intubated, so she decides to
crush the pills and instill them into his
nasogastric (NG) tube. In her haste to give the
already-late medications, she fails to notice the
“Do not crush” warning on the electronic
medication administration record. She crushes
an extended-release calcium channel blocker
and administers it through the NG tube. An hour
later, the patient’s heart rate slows to asystole,
and he dies…because of Administration error
 Transcription is a process of making an identical copy
of prescription in the medical records. Error that
occurs during this process is known as Transcription
Error.
 Several sheets of paper and stages from physician’s
order to drug delivery may cause confusion and add
to the possibility of transcription errors.
 Contributing factors include incomplete or illegible
prescriber orders; incomplete or illegible nurse
handwriting; use of abbreviations; and lack of
familiarity with drug names.
 In addition to errors associated with transcribing the
drug name, there is also opportunity for errors when
transcribing the dose, route or frequency.
 Error that occurs during the process of
indenting
 It includes wrong drug, wrong strength,
Wrong dose, Wrong route and frequency.
Category Event
A Circumstances or event that has a
capacity to cause error.
B Error occurred but didn’t reach the
patient.
C An error occurred that reached the
patient but did not cause any harm.
D An error occurred that reached the
patient and required monitoring to
confirm that it resulted in no harm to the
patient and /or required intervention to
preclude harm.
E An error occurred that may have
contribute to or resulted in temporary
harm to the patient and required
intervention.
Category Event
F An error occurred that may have
contribute to or resulted in temporary
harm to the patient and required transfer
to other unit/critical care.

G An error occurred that may have

contribute to or resulted in permanent
harm of the patient.

H An error occurred that required

intervention to sustain life.

I An error occurred that may have

contribute to or resulted in patient.