Elsevier

Mayo Clinic Proceedings

Volume 89, Issue 8, August 2014, Pages 1116-1125
Mayo Clinic Proceedings

Special article
Medication Errors: An Overview for Clinicians

https://doi.org/10.1016/j.mayocp.2014.05.007Get rights and content

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.

Section snippets

Medication Error Terms and Definitions

Medication error terminology can be confusing because of overlapping definitions.7 In health care, an error has been defined by the IOM as “the failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning). An error may be an act of commission or an act of omission.”8 A medication error has been defined by Bates et al5 as “any error occurring in the medication use process” and focuses on problems with the delivery

Incidence of and Harm From Medication Errors

The IOM's To Err is Human estimated, on the basis of an older study, that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths.1 The IOM later summarized the literature on medication error incidence rates in their 2007 report Preventing Medication Errors.9 Individual studies have reported inpatient medication error rates of 4.8%4 to 5.3%.5 In another study, prescribing errors for inpatients occurred 12.3 times per 1000 patient admissions.15

Error rates are influenced by

Risk Factors for Medication Errors

There are patient, health care professional, and medication factors that are associated with the risk of a medication error (Figure). Decline in patients' renal or hepatic function is associated with higher medication error rates.23 Additionally, patients' impaired cognition, comorbidities, dependent living situation, nonadherence to medications, and polypharmacy may also increase the risk of medication errors.24

Advanced age is a patient-related risk factor for medication errors. The American

Avoiding Medication Errors

Because the root causes of medication errors are diverse, multiple strategies are required to prevent them. The FDA has worked to review confusing drug names, improve packaging, require identification bar codes, and educate patients.29 Campaigns such as the “5 Rights of Medication Administration”—right drug, right patient, right dose, right route, right time—have been used with limited success. The elimination of cognitive bias in medicine is a difficult problem to overcome. Systems thinking

Disclosure of Errors

Disclosure of medication errors is import for the benefit of an individual patient, as well as to provide data for broader, systemic insights into any recurring patterns of errors.21

Studies have examined patient attitudes toward disclosure of medical and medication errors. In general, patients and their families want transparent communication and full disclosure when an error occurs.45, 46 In addition, most patients want to know about an error even if there was no detrimental outcome, and they

Conclusion

Medication error is an important cause of morbidity and mortality, yet it can be a confusing and underappreciated concept (Table). A medication error is any error that occurs in the medication use process. It has been estimated by the IOM that mediation 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

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      p. 549) ME occurs when there is a failure in one or more of the rights of medication administration, including right medication, right patient, right dose, right time, right route, right reason, right documentation, right form, and right response.2–4 Moreover, ME can occur at any stage of the medication process (prescription,5,6 transcription,7,8 preparation,9,10 dispensing,11,12 administration6,13 and documentation,14 or monitoring the patient response15), either with adverse events or not.3,16 According to the NCC MERP,17 there are nine ME categories starting from events that have the capacity to result in error to error that could result in death.

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    For editorial comment, see page 1027; for a related article, see page 1042

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