Medication Errors: An Overview for Clinicians

Abstract

Medication error is an important cause of patient morbidity and mortality, yet it can be a confusing and underappreciated concept. This article provides a review for practicing physicians that focuses on medication error (1) terminology and definitions, (2) incidence, (3) risk factors, (4) avoidance strategies, and (5) disclosure and legal consequences. A medication error is any error that occurs at any point in the medication use process. It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths. Medication factors (eg, similar sounding names, low therapeutic index), patient factors (eg, poor renal or hepatic function, impaired cognition, polypharmacy), and health care professional factors (eg, use of abbreviations in prescriptions and other communications, cognitive biases) can precipitate medication errors. Consequences faced by physicians after medication errors can include loss of patient trust, civil actions, criminal charges, and medical board discipline. Methods to prevent medication errors from occurring (eg, use of information technology, better drug labeling, and medication reconciliation) have been used with varying success. When an error is discovered, patients expect disclosure that is timely, given in person, and accompanied with an apology and communication of efforts to prevent future errors. Learning more about medication errors may enhance health care professionals' ability to provide safe care to their patients.

Perceived contributory factors to medication administration errors (MAEs) and barriers to self-reporting among nurses working in paediatric units of selected referral hospitals in Rwanda

“…29 With regard to their religion a half of the participants were catholic 75 (50.34%) which is in relation to the religious population in Rwanda whereby the big number is from catholic church at 44%. 30 Regarding the marital status the majority of the participants were married 104 (69.8%) similar to the marital status of Rwandan population which is on 46.1%. 30 The majority of participants in this study were bedside nurses 133 (89.3%) of course in nursing practice bedside nurses are more than the managers.…”

Medication at discharge in an orthopaedic surgical ward: quality of information transmission and implementation of a medication reconciliation form

“…All patients admitted to the orthopaedic surgery ward who had at least two chronic diseases and three usual medications on their BPMH were considered to benefit from a BPMDL at discharge, given the higher likelihood of medication errors occurring during hospitalization [17,18]. The BPMDL was based on the Lund Integrated Medicines Management-Discharge Information model, established and validated by pharmacists and orthopaedic surgeons.…”

Evaluating a Serious Gaming Electronic Medication Administration Record System Among Nursing Students: Protocol for a Pragmatic Randomized Controlled Trial (Preprint)

“…Using a finite-state machine logic, each of these feedback loops could result in either success, qualified success, or failure in the administration process, which would be reported back to the student upon their completion of the medication administration event. Since medication errors are commonly generated through a range of dynamic procedural, clinical decision-making, human and environmental factors [28], the game was designed to be as expansive as possible for students to generate eMAR-enabled errors of all complexions, including: incorrect medication dosage interpretation; administration timing; clinical indication and appropriateness; and, other best practice processes deviations (eg, failure to hand wash prior to administration; failing to barcode scan the patient identification band or medication barcode; failing to complete a vital signs assessment prior to administering an anti-hypertensive medication, etc). If a student failed to attend to a specific medication administration best practice, and further dependent on the severity of the error, feedback would be provided to the student upon completion of the scenario, informing them of the number of errors made and brief rationale related to the mechanism of the error(s) themselves.…”