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Pharmaceutical Association of Mauritius



Medication errors

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm

Medication Errors

  • 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 wrong time
  • Health-system pharmacists play a very active and important role in procedures to prevent medication errors.



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

A suggested protocol for handling medication errors (Pdf format)

Understanding Medication Errors - US Pharmacopeia

The Institute for Safe Medication Practices



Avoiding Medication Errors

 Be an Informed Consumer

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 expect answers.

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!

Key Questions

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:

  1. What are the brand and generic names of the medications?
  2. What does it look like?
  3. Why am I taking it?
  4. How much should I take, and how often?
  5. When is the best time to take it?
  6. How long will I need to take it?
  7. What side effects should I expect, and what should I do if they happen?
  8. What should I do if I miss a dose?
  9. Does this interact with my other medications or any foods?
  10. Does this replace anything else I was taking?
  11. 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 instructions.
  • Turn on the lights to take your medications. If you can't see what you're taking, you may take the wrong thing.
  • 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 dangerous.
  • 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 prevent errors.
  • 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 have allergies.
  • 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.