Special articleMedication Errors: An Overview for Clinicians
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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