A medication error
is any preventable event that may cause or lead to inappropriate medication use
or patient harm
- Medication errors should not be confused
with adverse drug reactions -- excessive response to a medicine that
is unexpected and undesired.
- A recent study revealed that prescription
errors decreased by 66% and a projected $270,000 per year was saved
when pharmacists were included on patient rounds in the ICU of a large
urban teaching hospital (Journal of the American Medical
Association, July 1999)
- Medication errors account for 1 out of
131 outpatient deaths and 1 out of 854 in-patient deaths (Institute of
Medicine Report, To Err is Human, November 1999).
- Medication errors may be committed (or
contributed to) by anyone who handles medicine, including physicians,
nurses, pharmacists, patients and their caregivers.
- Types of medication errors include:
- Doctor’s handwriting is misread
- Abbreviation is misinterpreted
- Two similarly named drugs are confused
- Similar-looking packages containing
different drugs are switched
- A concentrated drug is used in place of
a dilute dose
- Dosage directions are not clear
resulting in doses that are too much, too little, or given at the
- Health-system pharmacists play a very
active and important role in procedures to prevent medication errors.
Always Know Exactly What You Put in Your Mouth - ISMP
How to Take Your Medications Safely - ISMP
Preventing Medication Error - US Pharmacopeia
To Help Prevent Medication Error - US Pharmacopeia
Understanding Medication Errors - US Pharmacopeia
suggested protocol for handling medication errors (Pdf format)
Understanding Medication Errors - US Pharmacopeia
Institute for Safe Medication Practices
Avoiding Medication Errors
The more information you have on
medication error, the better
able you are to to prevent errors and to take care of yourself. You have to ask
your pharmacists, doctors and nurses about your medications, and you have to
Also, if you have any chronic illnesses,
pick up one of the consumer guides about medications at a bookstore or from the
library. Find out all that you can about your illnesses and the medications you
are taking. What you learn will help protect you later.
Your doctors, nurses and pharmacists work
hard to keep you healthy, but you are also responsible. Learn what questions to
ask. Expect answers--it's your life and your health!
Your pharmacist can be your partner to
prevent medication errors. Find one who offers services like monitoring your
therapy and keeping a complete list in the pharmacy computer of all your
medications and chronic medical conditions. Include over-the-counter
medications, vitamins, nutritional supplements and herbal products even if you
bought them somewhere else. It's worth the cost. With this information in one
place, your pharmacist can help to protect you against harmful drug
interactions, duplicate medications and other potential problems. Before you
leave the pharmacy, your pharmacist should give you printed information about
the medication and make sure that you understand the answers to these questions:
- What are the brand and generic names
of the medications?
- What does it look like?
- Why am I taking it?
- How much should I take, and how often?
- When is the best time to take it?
- How long will I need to take it?
- What side effects should I expect, and
what should I do if they happen?
- What should I do if I miss a dose?
- Does this interact with my other
medications or any foods?
- Does this replace anything else I was
- Where and how do I store it?
When you buy over-the-counter
medications, read the labels carefully because they might contain ingredients
you do not want or should not take. Maybe they will interact with your other
medications, cause an allergic reaction, or not be correct for your symptoms.
Ask your pharmacist for help if you have trouble selecting the right product.
What You Can Do...
. . . at home:
- Make a list of medications you are
taking now. Include the dose, how often you take them, the imprint on each
tablet or capsule, and the name of the pharmacy. The imprint can help you
identify a drug when you get refills.
- Any time that your medications change,
change your list, too. Double-check the imprints on the tablets and capsules.
- Also list your medication and food
allergies, and any over-the-counter medications, vitamins, nutritional
supplements or herbal products that you take regularly.
- Keep medications in their original
containers. Many pills look alike, so by keeping them in their original
containers, you will know which is which and how to take them.
- Never take someone else's medication.
You don't know if it will interact with your medications, the dose may be
wrong for you, or you may be allergic to it.
- Read the label every time you take a
dose to make sure you have the right drug and that you are following the
- Turn on the lights to take your
medications. If you can't see what you're taking, you may take the wrong
- Don't store medications in the
bathroom medicine cabinet or in direct sunlight. Humidity, heat and light can
affect medications' potency and safety.
- Store medications where children can't
see or reach them, for example, in a locked box or cabinet.
- Keep medications for people separate
from pets' medications or household chemicals. Mixups are common and can be
- Don't keep tubes of ointments or
creams next to your tube of toothpaste. They feel a lot alike when you grab
quickly, but a mistake could be serious.
- Flush any old medications, including
used patches, down the toilet. Children and pets might get into medications
that are thrown into the wastebasket, and some drugs actually become toxic
after the expiration date.
- Don't chew, crush or break any
capsules or tablets unless instructed. Some long-acting medications are
absorbed too quickly when chewed, which could be unsafe. Other medications
either won't be effective or could make you sick.
- To give liquid medication, use only
the cup or other measuring device that came with it. Dosing errors can happen
if you use a different cup or if you use the cup with other liquids because
the cups often are different sizes or have different markings. Also, household
teaspoons and tablespoons are not very accurate, which is important with some
medications. Your pharmacist may give you a special oral syringe instead.
. . .in the hospital:
- Take your medications and the list of
your medications with you when you go to the hospital. Your doctors and nurses
will need to know what you are taking.
- After your doctor has seen them, send
your medications home with your family. While you are in the hospital you may
not need the same medications.
- Tell your doctor you want to know the
names of each medication and the reasons you are taking them. That way, if
anyone tells you anything different, you'll know to ask questions, which might
- Look at all medicines before you take
them. If it doesn't look like what you usually take, ask why. It might be a
generic drug, or it might be the wrong drug. Ask the same questions you would
ask if you were in the pharmacy.
- Do not let anyone give you medications
without checking your hospital ID bracelet every time. This helps prevent you
from getting someone else's medications.
- Before any test or procedure, ask if
it will require any dyes or medicines. Remind your nurse and doctor if you
- When you're ready to go home, have the
doctor, nurse or pharmacist go over each medication with you and a family
member. Update your medication list from home if any prescriptions change or
if new medications are added.
. . .at the doctor's office:
- Take your medication list every time
you go to your doctor's office, especially if you see more than one doctor.
They might not know about the medications other doctors prescribed for you.
- Ask your doctor to explain what is
written on any prescription, including the drug name and how often you should
take it. Then when you take the prescription to the pharmacy, you can
double-check the information on the label.
- Tell your doctor you want the purpose
for the medication written on the prescription. Many drug names look alike
when written poorly; knowing the purpose helps you and the pharmacist
double-check the prescription.
- If your doctor gives you samples, make
sure that he or she checks to be sure that there are no interactions with your
other medications. Pharmacies have computers to check for drug interactions
and allergies, but when your doctor gives you samples, this important check
may be missed.