Medication Dispensing Errors and Prevention

Function

Medication errors can occur at any time during the treatment process. Various healthcare professionals must go through multiple steps when a patient is prescribed a medication. The following steps outline potential places where medication errors may occur.

• Ordering and prescribing
• Documenting
• Transcribing
• Dispensing
• Administering
• Monitoring

Medication errors most commonly occur during the prescribing, ordering, and administration stages. Nearly 50% of all medication errors occur when a medication is prescribed or ordered. Studies reveal that nurses and pharmacists identify 30% to 70% of medication-ordering errors. Medication errors are a pervasive but preventable problem.[11]

Issues of Concern

Preventing medication errors requires an understanding of the causes and types of medication errors as well as when during the prescribing process mistakes can occur. 

System Failures

• Inaccurate order transcription
• Drug knowledge dissemination
• Failing to obtain an allergy history
• Incomplete order checking
• Mistakes in the tracking of the medication orders
• Poor interprofessional communication
• Unavailable or inaccurate patient information

According to the World Health Organization's publication titled "Medication Errors: Technical Series on Safer Primary Care," the following factors have been associated with an increased risk of medication errors in the primary care setting:

• Lack of therapeutic training or inadequate knowledge
• Poor communication with patients
• A language barrier between healthcare professionals and patients
• Increased workload
• Interruptions and distractions
• Lack of accuracy of patient records and a poor interface between prescriber and electronic health records
• Lack of protocols and standardized procedures in the work environment
• Inadequate naming, labeling, and packaging of medicines
• Poor communication with secondary care providers

 Types of Medication Errors

• Prescribing
• Omission
• Wrong time
• Unauthorized medication
• Improper dose
• Wrong dose prescription or wrong dose preparation
• Administration errors such as incorrect route of administration, administering the drug to the wrong patient, extra dose, or wrong rate
• Monitoring errors such as failing to take into account the patient's liver and renal function, failing to document allergy or potential for drug interaction
• Compliance errors such as not following protocol or rules established for dispensing and prescribing medications 

Common Causes of Medication Errors

Expired Product

Usually occurs due to improper storage of preparations resulting in deterioration or use of expired products.

Incorrect Duration

Healthcare professionals make incorrect duration errors when they administer medications for a duration either longer or shorter than prescribed.

Incorrect Preparation

Incorrect preparation errors usually occur with compounded prescriptions or medications that require a specific diluent for reconstitution. 

Incorrect Strength

Incorrect strength may occur at many points in the medication process. Human error is often the cause when similar bottles or syringes with the incorrect strength are selected.

Incorrect Rate

Incorrect rate of administration most often occurs with medications given as IV push or infusions. The result may be significant adverse drug reactions like tachycardia due to rapid IV epinephrine or vancomycin flushing syndrome due to the rapid administration of vancomycin.

Incorrect Timing 

Being completely accurate with scheduled doses in both home and healthcare settings is challenging. Significant alterations in the absorption of some medications occur in the presence or absence of food. The result may be underdosing or overdosing.

Incorrect Dose

Incorrect dosing includes overdose, underdose, omission of, or an extra dose. Not administering a scheduled dose of a medication is an error of omission. Errors due to incorrect routes usually occur due to unclear labeling or tubing that is adaptive to multiple connectors or lines of access. Incorrect routes often result in significant morbidity and mortality.[12][13][14]

Incorrect Dosage Form

An incorrect dosage form occurs when a patient receives a dosage different than prescribed, such as immediate-release instead of extended-release.

Incorrect Patient Action

Patients incorrectly taking a medication is considered a medication error. Patient education is the only way to prevent this type of error.

Known Allergen

Dispensing a drug that the patient is allergic to is often due to poor communication with the patient, inappropriate chart review, inaccurate charting, or lack of a technological interface.

Known Contraindication

Review medications vigilantly for drug-drug, drug-disease, or drug-nutrient interactions.

Distractions

One of the significant causes of medication errors is distractions and interruptions during the prescribing process or the administration process of medications.[15] 

Distortions

Most distortions originate from poor writing, misunderstood symbols, abbreviations, or improper translation. Some distortions may occur when the prescribed medication is unavailable and is subsequently substituted for a different drug by a non-prescribing clinician.

Illegible Writing

Illegible writing has plagued the healthcare industry for decades. The Institute of Safe Medication Practices recommends eliminating handwritten orders and prescriptions.[16]

Clinical Significance

Several factors increase the risk of medication errors, including older age, an overburdened healthcare system, an elevated number of prescribed drugs, comorbidities, and multiple prescribers for one patient. Medication errors, in turn, contribute to various adverse outcomes, such as drug-drug interactions, a higher number of hospital admissions, increased outpatient visits, prolonged hospital stays, elevated patient management costs, and heightened patient mortality risk.

In addition to affecting patients and their families, medication errors may cause emotions like shame, guilt, and self-doubt, which can lead to suicidal tendencies in some healthcare professionals. Legal actions can impact the professional advancement of healthcare providers and may even lead to license revocation, causing additional emotional distress alongside the stress from the medication error itself.

Globally, medication-related errors are responsible for 5% to 41.3% of all hospital admissions and 22% of readmissions after discharge. The incidence of medication errors is 30% higher in patients who are prescribed five or more drugs and 38% higher in those 75 years or older. Patients 65 years or above experience nearly double the medication-related admissions compared to their younger counterparts.

Healthcare professionals who commit medication errors face potential consequences, including losing patient trust, civil legal actions, criminal charges, and disciplinary actions by medical boards. According to the Institute of Medicine's report, "To Err is Human," medication errors were estimated to cause 1 in 131 outpatient deaths and 1 in 854 inpatient deaths, based on an older study.

Other Issues

Medical Error Disclosure 

Creating an environment that focuses on the healthcare team's respect and compassion for patients, along with dedication to providing high-quality care and ensuring patient safety, requires prompt and full disclosure of a medication error once identified.[17]

The patient and family should understand what happened and the harm caused and receive an explanation of the measures taken to minimize the harm, if possible. The interaction should also allow the patient and their family to ask questions.[17]

Disclosure of medication errors should also include disclosure to regulatory agencies and institutional committees so that implementation of organizational changes can prevent such errors in the future.[17] Care must be taken to avoid individual blame. To better standardize medication reporting, the Agency for Healthcare Research and Quality developed the Common Formats, which defined data elements collected and reported in case of a medication error through the Patient Safety Organization Privacy Protection Center. The scope of the Common Formats encompasses all errors, including events that have the potential to affect the patient, near-misses, and those that have a patient effect.[18][19][20]

Analyzing Medication Errors and Sentinel Events

The most commonly utilized methods of evaluating and assessing factors that led to a sentinel event or medication error include root cause analysis and failure mode effect analysis. 

Root Cause Analysis

A root cause analysis (RCA) identifies the causative factors that underlie variations in performance.[21] The Joint Commission, the accreditation agency for healthcare facilities in the United States, requires healthcare institutions to perform a root cause analysis after all sentinel events. This process uncovers the causative factors that resulted in a sentinel event, and forming an action plan helps prevent future recurrences. A root cause analysis helps discover the causes of errors by focusing primarily on systems and processes, not on the actions of the individuals involved. The team identifies changes in systems and processes that will improve performance and reduce the incidence of repeat sentinel events.[21]

For example, a clinician prescribes azithromycin for a patient allergic to erythromycin, and the patient develops anaphylaxis as a result of this error. In that case, the hospital must initiate a root cause investigation. The RCA team develop an action plan, which may include educating the entire medical staff on drug-drug interactions and medication similarities and implementing an electronic medical record "stop alert" to prevent this error from reoccurring.

The Joint Commission receives a copy of this RCA and action plan, aggregates all RCA reports from various facilities, and publishes risk-reduction strategies in the "Sentinel Event Alert" newsletter.

If a healthcare agency neglects to conduct an RCA, the institution may face an "accreditation watch." A publicly disclosed indication that a sentinel event occurred without an acceptable action plan. When a sentinel event threatens patient health and safety, the Joint Commission carries out onsite reviews.

Failure Mode Effect Analysis

Failure mode effect analysis fosters safety and the prevention of accidents by proactively identifying potential or actual failures, causes, and effects. Failure mode effect analysis concludes that errors will occur even if healthcare professionals are careful. Failure mode effect analysis engages in a continual quality improvement process to assess and correct areas where an error has or is likely to occur. The strategy with failure mode effect analysis is to build redundancies to serve as safety nets that trap errors.[22]

Reducing Medication Errors

Healthcare delivery occurs in a dynamic environment with multiple variables, requiring quick critical decision-making. As a result, implementing strict operational processes like those utilized in other high-risk industries, such as aviation, proves difficult.[23] Hence, reducing medical errors, particularly medication errors, necessitates a multifaceted approach at various healthcare levels, as outlined below.

Encourage Error Reporting

The first crucial step involves promoting the reporting of medical errors, ensuring that adverse events and "close calls" are consistently highlighted as they occur. Healthcare facilities should address any barriers to medical error reporting to enhance patient safety. The most common barrier to such reporting is the fear of facing the consequences.[23] To reduce this fear and encourage medical error reporting, a change in workplace culture to adopt effective strategies for addressing medical errors is essential. Embracing a patient safety culture that empowers clinicians to identify medical errors that could harm patients has proven effective in overcoming the fear of consequences.

Healthcare professionals' limited understanding of what constitutes a medical error often results in underreporting.[23] Clinicians require ongoing education on identifying medical errors. This education should cover the definition of a medical error, adverse drug events, and sentinel events, as well as how to report them and the expected consequences. 

Automated Electronic Health Records with Computerized Physician Order Entry

According to a recent Cochrane review, several technological interventions can decrease the frequency of medication errors in acute hospital settings.[24] Some of these interventions are:

• Computerized physician order entry (CPOE)
• Clinical decision support systems (CDSS)
• Barcode identification of patients and their corresponding medications
• A recent study from Portugal reported that the use of electronic medical records not only reduced medication errors but also "contributed to a continuous improvement in patients' safety."[25] Another study noted a significant reduction in prescribing errors with the use of computerized medication reconciliation and pharmacist-led medication reconciliations.[26] 

Computerized physician order entry systems are the single most effective method for reducing medication errors.[26] Computerized physician order entry systems replace paper-based ordering systems, allowing clinicians to maintain an online medication administration record with real-time reviews of modifications made to orders by other clinicians and personnel.[26] 

According to the World Health Organization's (WHO) publication titled "Medication Errors: Technical Series on Safer Primary Care," multiple trials of computerized medication order entry have shown a reduction in medication errors, with some studies reporting a decrease of at least 50%. The publication also noted that adding clinical decision support systems and alerts can further decrease this error rate, particularly if targeted to high-risk medications. The WHO rightly cautions against excessive use of "stop alerts" as this can lead to alert fatigue and render them useless. With a reduced medication error risk of 48% in hospital settings, the benefit of CPOE is not limited to primary care settings. 

 Medication Reconciliation

Medication review and reconciliation can decrease common medication errors, especially in hospitals. Medication reconciliation is documenting a definitive list of medications prescribed for the patient and that the patient is currently taking. Ideally, it should also include a list of over-the-counter supplements and medications. The WHO publication "Medication Errors: Technical Series on Safer Primary Care" reports a decreased risk of medication adverse events with medication reconciliations in primary care settings with established physician-patient relationships. In the hospital setting, the publication notes a decreased rate of medication adverse events when a pharmacist performs the medication reconciliation.

Medication reconciliation is particularly helpful at the point of discharge, especially from an inpatient setting. The WHO publication noted a poor accuracy of medication reconciliation at the time of discharge from most facilities worldwide. Performing an accurate medication reconciliation at discharge is highly recommended by the WHO to help decrease medication errors and adverse drug events.

Optimize Nursing Workflow to Minimize Interruptions During Medication Administration

In the hospital setting, optimizing workflow to minimize interruptions during medication preparation and administration is essential in preventing medication errors. A 2017 study from Australia reports that interruptions during medication administration and preparation are associated with procedural failures, clinical errors, and compromised patient safety.[27]

Automated medication dispensing systems and medicine packaging decrease the need for preparation at the patient's bedside and help decrease the time nurses require for medication administration. A distraction-free period and zone should be used during medication administration to minimize interruptions. In critical care and hospital-based settings, this may only sometimes be feasible. However, implementing a "do not interrupt" intervention for nurses engaging in medication administration reduces non-medication-related interruptions from 50 per 100 administrations to 34 per 100 administrations.[28]

Prescribing Recommendations for Clinicians and Minimizing Errors When Using Handwritten Prescriptions

Approach Every Prescription with Caution

Not only do many medications share similar names, but they also have multiple uses and alternative names. When the prescription lacks a specific diagnosis, a risk of either overprescribing the drug for an extended duration or providing an insufficient amount of the medication exists.

Write Down the Precise Dosage

Distortion of a dose can quickly occur when using nonspecific abbreviations or decimal points without thought. One abbreviation often causing medication errors is the "Ug" symbol. Often mistaken for units instead of micrograms, the best course of action is to spell out the word micrograms.

Use Metric Measures

The use of apothecary measures is now part of the historical archives; weight measures like grains, drams, and minims have little meaning to modern-day healthcare clinicians. Instead, use the universal metric measures that pharmacists and clinicians prefer. Use caution when placing the decimal point when using metric measures. For example, when writing dexamethasone 2.0 mg, the nurse or the pharmacist may think this prescription reads 20 mg if the decimal point is not clearly visible. On the other hand, a zero should always precede a decimal point. For example, write digoxin as 0.25 mg, not .25 mg. Again, if the decimal point is unclear, the patient may receive a tenfold increase in dose.

Consider Patient Age

Always check the patient’s age and body weight for the correct dose. Include the patient's age and weight so the pharmacist understands the dosage calculation. In children, most drugs are prescribed based on body weight.

Liver and Kidney Function

Consider renal or liver function. Patients with renal and liver dysfunction may require lower doses. Toxicity can result from the failure to excrete or break down the medication.

Provide Directions

Healthcare professionals who write drug orders and prescriptions should never assume that the other party understands what the prescriber is thinking. Provide clear instructions on doses, the number of pills, and how and when to take the medication. Orders like "take as directed" are a recipe for disaster. Similarly, "prn" without an indication should never be used. Be specific and include when the medication is necessary and for what purpose. For example, morphine 2 mg, take one pill every 3 to 4 hours as needed for pain. These steps provide clear instructions to the dispensing pharmacist and will avoid errors. Reducing medication errors requires open communication between the clinician, the patient, and the pharmacist.[29]

Use of Abbreviations

Abbreviations are a potential cause of medication errors. Often, the frequency of administration is abbreviated using suffixes like QD, OS, TID, QID, and PR. QD, meaning once a day, can easily be mistaken for QID or four times daily. Additionally, these abbreviations can have several other meanings and lead to misinterpretation. Avoid the use of abbreviations when writing medication orders.[30]

Duration of Treatment

Specify the duration of treatment and ensure the duration matches the number of pills prescribed. When writing the quantity of the drug, write down the actual number of pills as opposed to stating dispense for 2 months. Providing a specific number of doses ensures the patient will receive appropriate follow-up and not stockpile medications. If the patient has a chronic disorder, the clinician should treat each flare-up as a single event with a finite number of pills.

Remain Alert for High-risk Medications

Prescribe only enough high-risk medications until the next follow-up appointment is necessary. For example, if a patient has a deep vein thrombosis or a prosthetic heart valve and requires warfarin, only prescribe for 4 weeks at a time and reassess the patient at each visit. Do not give warfarin for many months at a time. Routine INR monitoring is essential, and the dose may require an adjustment.[31]

Specify the Indication for the Drug

Since many medications have multiple uses, including the indication for the drug is highly recommended. Unfortunately, most prescriptions never have the diagnosis written, and omitting this information increases the potential for complications. Writing the diagnosis informs the pharmacist and reminds the patient of the medication's purpose. This small step can facilitate counseling by the pharmacist, reinforce the patient's treatment plan, and provide ample opportunities for patient education. This step also improves communication between the healthcare professional and the pharmacist.[32]

Appropriate medication for the Patient Population

When treating elderly patients, healthcare professionals should access the Beers Criteria list of Potentially Inappropriate Medication. This list contains medications that may be inappropriate for patients 65 and older. A trained healthcare professional must consider the patient's overall health, current medical conditions, and other medications.[33]

Add Supplemental Instructions

Add extra precautions when necessary. For example, when prescribing tetracyclines, warn the patient about sun exposure, or when taking ibuprofen, advise the patient to take the medication with food. When prescribing metronidazole, warn the patient about alcohol use. Do not assume the pharmacist will add these extra warnings when dispensing medications. For patients who cannot read or understand the instructions for prescribed medications, educate the family and provide verbal counseling.

Discuss Patient Preferences

Considering the many drugs available to treat a single disorder, clinicians should involve the patient in decision-making regarding prescription medications. Patients require education about the potential adverse effects and precautions to help them make an informed decision.

Write Contact Information

Many healthcare providers write prescriptions or orders in the chart and often do not leave a contact number. If there is a query about the drug, the patient misses out on the medication or experiences a delay in treatment. A simple step like adding a contact number can eliminate this source of error.

Pharmacy Error Prevention

Errors by pharmacists are usually judgmental or mechanical. Judgmental errors include failure to detect drug interactions, inadequate drug utilization review, inappropriate screening, failure to counsel the patient appropriately, and inappropriate monitoring. A mechanical error is a mistake in dispensing or preparing a prescription, such as administering an incorrect drug or dose, giving improper directions, or dispensing the incorrect dose, quantity, or strength.

The most common causes of pharmacy-driven medication errors include workload, similar drug names, interruptions, lack of support staff, insufficient time to counsel patients, and illegible handwriting. Pharmacies should develop protocols to standardize internal processes and ensure:

• Delivery of the correct dosage
• Identify contraindications to drug therapy
• Identify a drug allergy
• Monitor drugs with narrow therapeutic indexes
• Recognize drug interaction
• Recognize knowledge deficits

A pharmacist is often responsible for supervising the patient's medication treatment and notifying the healthcare team when a discrepancy occurs. In the acute care setting, most medication discrepancies are found at discharge, highlighting the need for a pharmacist to assist in the discharge process.[34]

Spending time with the patient to ensure they understand the drug dose, route, and frequency, along with a review of drug allergies and any potential drug interactions, will reduce medication errors. Barriers to successful communication in the pharmacy setting include the inability to reach prescribers, unclear verbal and written orders, and time constraints that make it challenging to check drug interactions.[35]

Enhancing Healthcare Team Outcomes

While most healthcare professionals do not anticipate medication errors, they remain a common occurrence. A recent study from Norway revealed that 5.2% of all medication errors were linked to severe harm to patients, with 0.8% of these errors resulting in fatalities.[36] Recognizing the extent of this issue marks the initial step toward enhancing patient safety and reducing medical errors.

No single method exists to eradicate all medication errors, but healthcare professionals can reduce errors by increasing vigilance and fostering close collaboration with fellow clinicians, pharmacists, and patients. Open and direct communication is one approach to bridging the safety gap and lowering the rate of medication errors. Effective communication ensures all relevant information is available to all healthcare professionals involved in care delivery. 

An interprofessional team of clinicians, nurses, and pharmacists can contribute to improved clinical outcomes and enhanced patient safety through accurate medication reconciliations, clear prescription orders, and standardized verbal order entries. An environment of teamwork is most conducive to optimal medication delivery, where team members are unafraid to discuss and resolve conflicts. Any lack of interprofessional communication hinders the identification of medication errors and their underlying causes. Encouraging open discussions within the team and implementing proven strategies to minimize medication errors can significantly enhance patient safety.