Mr. Nelson is a PharmD candidate at
Thomas J. Long School of Pharmacy
and Health Sciences, University of
the Pacific in Stockton, California.
Dr. Nguyen is a clinical pharmacist
at Fountain Valley Regional Hospital
in Fountain Valley, California. Dr.
Pham is assistant professor of pharmacy
practice at Western University
College of Pharmacy and Health
Sciences, in Pomona, California.
When the Institute of Medicine
(IOM) released To Err is
Human—its series of reports
examining the quality of health care
in the United States—these reports
caught the public's attention more
than other health policy issues in the
past.1 Congress scheduled hearings, and
President Clinton called on federal agencies
to implement the IOM's recommendations.2 The reports addressed 4
major issues: (1) errors are common
and costly; (2) systems cause errors; (3)
errors can be prevented, and safety can
be improved; and (4) patient safety must
become a national priority.
Types of Medication Errors
According to the Joint Commission
on Accreditation of Healthcare Organizations,
the inpatient medication management
process has 6 major steps:
selection and procurement, storage,
ordering and transcribing, preparing and
dispensing, administration, and monitoring.3 Although errors can occur during
any step of this process, a logical first
step is to target the processes where
most errors occur. MEDMARX, the US
Pharmacopeia's national database for
medication errors, reveals that most
medication errors (30%) occur during the
administration stage.4 The prescribing,
transcribing, and dispensing stages were
each responsible for >20% of all medication
errors (Table 1).
Source of Medication Errors
Percentage of errors
Adapted from reference 4.
According to a study that examined
the frequency and variety of medication
errors in 36 health care facilities (24 of
which were hospitals), the most common
category of error, besides "dose administered
late," was omission error
(30% of all
errors), meaning an ordered dose of medication
was not given to the patient. Other
common errors were "wrong dose" given
(17%) and "unauthorized drug" given (4%).
It also was found that a medication error
was made in about 1 of every 5 orders
Most errors can be attributed to the
performance deficit of a health care professional,
meaning that the professional
possesses the knowledge and training
to carry out his or her duty but fails to
do so.4 Breakdowns in communication
among health care team members also
can be a problem. These include the use
of unapproved abbreviations
orders, unclear written
or verbal orders leading
to inaccurate interpretations,
or mix-ups with
look-alike and soundalike
Although it may be
nearly impossible for a
hospital to ensure each
employee has and uses
the same level of professional judgment,
it is feasible to improve communication.
The Role of Technology
About 39% to 49% of medication errors
occur during drug ordering, according to
one recent study.7 Electronic medical
records (EMRs) have been successful
in reducing these errors. Health care
providers can access a patient's medical
records to view demographics, medical
history, progress notes, laboratory
and procedural results, and medications.
One study found that EMRs reduce medication
errors by 55%, compared with
paper-based systems; however, another
study found that <25% of US hospitals
and 20% of physician's offices
EMRs.8 Ideally, an EMR replaces paper
charts; if hospitals do not fully implement
a paperless system, however, an EMR can
coexist with paper charting.
Another technology similar to EMR
is computerized physician order entry
(CPOE), which allows physicians to order
medications by selecting the drug and
dosage listed on a computer screen. One
study found that CPOE reduces medication
errors by up to 81%.9 A survey-based
study revealed, however, that, of
662 respondents, only 17.4% were using
For paper-based systems, letterbox
and preprinted order forms are useful to
alleviate illegibility. For medications with
multiple indications, requiring physicians
to write indications can assist pharmacists in assessing appropriate
therapy. Also, preprinted order sets based on published guidelines
are recommended for such diagnoses as community-acquired pneumonia,
acute myocardial infarction, and patient-controlled analgesia.
Health systems also should take care to avoid the use of unapproved
abbreviations, trailing zeros, and lack of verbal/telephone
order read-backs. Health systems that post a list of unapproved
abbreviations throughout the hospital have been successful in
reducing errors. To enforce compliance, pharmacists should send
back incomplete orders with unapproved abbreviations, "prn"
orders without indications, or verbal/telephone orders without
Medication reconciliation is usually performed to ensure that
patients continue to receive medicines they were taking prior to
admission or transfer into another health system unit. More than
half of medication errors occur while patients are in transition.11
According to one study, when adult patients left the intensive care
unit, medication reconciliation eliminated nearly all errors.11
Health systems pharmacists who perform daily patient profile
reviews also have seen success. Having pharmacists review patient
diagnoses, medication profiles, and laboratory profiles for therapy
duplications, drug?drug interactions, dose adjustments, and appropriate
antibiotic coverage, has reduced errors significantly.
In other studies, nursing administration accounted for 26% to
38% of medication error occurrences in hospitalized patients.2,6,7
High-alert medications should require a double-check and a timeout
at bedside; they require 2 registered nurses' signatures on the
medication administration record before dispensation. Also, chemotherapies
require a time-out to check the 5 rights of medication
administration (Table 2) and patency of intravenous lines.
5 Rights in Medication Delivery
1. Right Patient
2. Right Drug
3. Right Dose
4. Right Route
5. Right Time
Infusion pumps account for up to 35% of errors, in which the most
common cause is incorrect manual programming.12
technology is capable of warning nurses when an error occurs.13
Bar coding has been useful in reducing medication errors.
Veterans Affairs hospitals saw an 86% reduction in errors after
implementing bar coding.7 Ideally, bar coding interfaces with EMRs
and pharmacy systems, so when an order is written, checked
against EMRs, processed, and labeled by the pharmacy with a
patient's unique bar code, the nurse can scan the medication label
and the patient's wrist band to assure the 5 rights are met.8
Education and technology, such as CPOE, bar coding, smart
pumps, as well as adverse drug event reporting, all contribute to
medication safety.6 Everyone involved in patient care must work
to prevent medication errors from occurring.
- Altman DE, Clancy C, Blendon RJ. Improving patient safety ? five years after the IOM report. N Engl J Med. 2004;351:2041-2043.
- Leape L, Epstein AM, Hamel MB. A Series on Patient Safety. N Engl J Med. 2002;347:1272-1273.
- The Joint Commission on Accreditation of Healthcare Organizations (2007, December 17). Joint Commission on Accreditation of Healthcare Organizations: Critical Access Hospital 2006 Medication Management. www.jointcommission.org/NR/rdonlyres/E6504BF2-E51E-4141-8777-E61380C10B91/0/06_cah_mm.pdf. Accessed December 23, 2007.
- Santell JP. Medication Error Prevention: Pearls for Health-System Pharmacists and Nurses. http://symposia.ashp.org/mederrors/overview.html. Accessed December 22, 2007.
- Barker K, Flynn E, Pepper G, Bates D, Mikeal R. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002; 162:1897-1903.
- Bates DW. Preventing medication errors: a summary. Am J Health-Syst Pharm. 2007;64:S3-S9.
- Benjamin MD. Reducing medication errors and increasing patient safety: case studies in clinical pharmacology. J Clin Pharm. 2003;43:768-783.
- Crane J, Crane F. Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010. Hosp Topics. 2006;84(4):3-8.
- Jayawardena S, Eisdorfer J, Indulkar S, Pal SA, Sooriabalan D, Cucco R. Prescription errors and the impact of computerized prescription order entry system in a community-based hospital. Am J Therapeutics. 2007;14(4):336-340.
- Inquilla CC, Szeinbach S, Seoane-Vazquez E, Kappeler KH. Pharmacists' perceptions of computerized prescriber-order-entry systems. Am J Health-Syst Pharm. 2007;64:1626-1632.
- Weitzel KW. Medication Reconciliation. Pharmacist's Letter. 2006;22:#220513.
- Rosenthal K. Smart pumps help crack the safety code. Nurs Manage. 2004;35(5):49-51.
- Husch M, Sullivan C. Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. Qual Saf Health Care. 2005;14:80-86.