Reducing medication errors has become a topic of top priority in our nation, with primary emphasis on improving patient safety. According to the National Coordinating Council for Medication Error Reporting and Prevention, a medication error is defined as a "preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer."1 Just as drugs can save lives, they can lead to harmful events affecting not only the patient, but also health care in general.

An array of studies has addressed the subject, as a large number of Americans die each year due to medication errors. In fact, according to the report of the Institute of Medicine (IOM) entitled "To Err Is Human: Building a Safer Health System," between 44,000 and 98,000 people die in hospitals as a result of medical errors, which, according to major studies, could have been prevented.2

For decades, minimizing adverse drug events and medication errors has been a goal in health care. Nevertheless, it is highly recognized that competent and caring professionals will make mistakes. When analyzing medication errors, the trend in the past has been to place possible negligence on the health care provider. Yet, today we realize that many medication errors result from inadequate systems leading to serious mistakes by providers.

Errors can occur during any stage of the medication process. Rather than upholding a punitive approach, however, now the focus is to concentrate on "prevention" and to devise strategies to minimize errors and adverse medication events. Although providers are still held to a high standard and must be responsible for the decisions they make, placing blame on an individual seldom leads to positive outcomes.

Medication Errors?An Overview

In an article published in the Journal of Clinical Pharmacology, David M. Benjamin, PhD, FCP, outlines "5 rights" in delivering drug therapy: (1) the right drug, (2) the right dose, (3) the right route, (4) the right time, and (5) the right patient.3 Yet, the system is far more complex. The incidence of medication errors in hospitals is at an all-time high, resulting in hospital administrators exploring new interventions conducive to an overall improvement in safety.

The report from the IOM states that patient awareness, based on patient education prior to discharge, also can provide a "major safety check" in hospitals. The aim is for patients to become familiar with the appearance of their medication, possible side effects, and the purpose for taking the medication?in essence, to create an awareness and a proactive approach to therapy on the part of patients.

Factors Contributing to Errors

The work environment in general can lead to errors?interruptions, an inadequately trained staff, sleep deprivation, language barriers, medication sound-alike names, and lack of data concerning a patient can become risks. A recent review article, "Medication Errors: A Bitter Pill" by Kathleen C. Ashton and P. W. Iyer of Rutgers University, outlines certain factors that lead to adverse medication events4:

  • Ordering errors. These errors occur when the physician orders the wrong drug, wrong dose, a drug to which a patient is allergic, or duplication in therapy. The nurse may then perpetuate the error by not questioning the physician. In addition, handwritten prescriptions can lead to catastrophic results, due to sloppy handwriting and confusion about decimal points.
  • Administering errors. These errors encompass the wrong drug, the wrong patient, and the wrong route. A common error in hospitals involves patient-controlled analgesia pumps. Although the advantage of the pump is the ability of the patient to obtain the right dose, if the pump has not been programmed correctly the patient may risk serious side effects.
  • Transcription errors. Entering incorrect data onto the medication administration record by nonmedical personnel can be a factor. Thus, nurses on duty need to have systems in place to detect potential errors.
  • Dispensing errors. Many of these errors involve the pharmacy's supplying an incorrect medication or dose; or they may occur when the pharmacy is closed. In her study, Dr. Ashton reported that the Joint Commission on the Accreditation of Healthcare Organizations now discourages access to the pharmacy by nurses after the pharmacy is closed.4

Implementing Crucial Systems Nationwide

Hospitals nationwide are exploring and developing systems for the purpose of reducing medication administration errors. The Valley Hospital, a 451-bed acute care facility in New Jersey, has worked diligently in developing a system to reduce medication administration errors. M. Mutter, of Clinical Systems and Quality Improvement, has determined certain factors that are necessary to achieving goals, namely (a) becoming familiar with the actual errors?concentrating on how, when, and why they were committed; (b) establishing a "nonpunitive" (whereby no punishment or disciplinary action is imposed for any specific error) approach whereby reporting of errors or "near-miss errors" (a process variation that does not affect an outcome but for which a reoccurrence carries a significant chance of a serious adverse effect) is encouraged; (c) identifying areas of concentrated errors; (d) standardizing steps in the identification of errors; and (e) selecting the proper technology to correct these errors.

A medical facility that represents a model in the area of reducing medication errors is the Kendall Regional Medical Center in Miami, Fla. Kendall Regional is highly committed to protecting patients and their well-being. Ana Caldera, director of pharmacy services, describes the system as one that prevents errors generated "from the dispensing as well as the administration end."

Kendall Regional has gone to great lengths to institute a system that encompasses a pharmacy robotics system to automate the dispensing of inpatient medications, as well as a barcode electronic medication administration system that ensures accuracy in administering the correct medication to the right patient, in the right dosage, and at the right time. Whereas many institutions utilize one or the other of these systems, Dr. Caldera has stated that Kendall Regional is the only hospital in South Florida that uses both systems in tandem to ensure optimal patient safety.

The robotic system at Kendall is called Serving Patients on Command (SPOC). Peter Jude, director of marketing and public relations at Kendall, has explained that each medication is prepared for the system by separating it into an individual unit dose. It is then sealed in an individual bag, labeled with a specific bar code, and prepared for retrieval and dispensing by SPOC.

The nurse on call later scans the bar code on the unit dose and matches it with the patient's bar-coded identification wristband. The verification process is performed via the "Electronic Medication Administration Record" to confirm that the medication is what is to be administered to the patient. Whereas Kendall Regional has devised its own effective system, many institutions nationwide have implemented ways to dispense medication with little or no error.

Role of the Pharmacist in Preventing Adverse Drug Events

The role of the pharmacist in reducing medication errors has been emphasized in various studies. A study conducted by Drs. La Pointe and Jollis, of the Division of Cardiology at Duke University Medical Center, found that many medication errors have occurred in hospitalized cardiovascular patients (eg, the wrong drug or dose).5 The authors concluded that the participation and contributions of a pharmacist on rounds have resulted in a decrease in errors. The value of a pharmacist on board was reiterated in a study by the Department of Pharmacy Services of Henry Ford Hospital, which found that the role of the pharmacists on rounds also has had a positive effect on preventing adverse drug events.6


Certainly, reducing medication errors requires a process that identifies where most errors occur and that implements a quality improvement system to minimize the risk of errors and develop the means to make adequate changes. The emphasis on reporting errors by employees in a good-faith, nonpunitive environment will lead to improved patient safety.

Dr. Pelegrin is the pharmacy manager of a Publix Pharmacy in Miami, Fla.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: