Medication errors in the United States healthcare system are a significant problem that can have serious consequences. These errors can result in adverse drug events, which range from mild to severe and can even lead to hospitalization or death.
The frequency of medication errors is also concerning, as studies suggest they are a leading cause of preventable harm in healthcare settings. Medication errors affect about seven million patients annually, resulting in about 3.5 million doctor’s office visits and one million emergency department visits yearly (Rasool et al., 2020).
Medication error prevention is a large part of patient safety. This bulletin provides an overview of different types of medication errors and offers some best practices to help healthcare providers prevent medication-related mistakes and the harmful consequences that may result.
Consider the following situations and best practices to help prevent medication errors. Medication errors can occur at any point in the medication use process, including prescribing, transcribing, dispensing, administering, and monitoring. Consider the following situations.
Errors by Medication Administration
Errors can result from administering a dose that was not ordered, administrating a drug in a different form than what was ordered, or using inappropriate procedures for administration, such as crushing an extendedrelease tablet.
Errors by Omission
Medication omissions occur when a medication is not provided to a patient because it has not been administered or has not been prescribed. Another omission error is failing to administer the medication on time, within 30 minutes before or after the scheduled time. Although an omission often causes no immediate threat to the patient, it can delay pain and symptom management, increase the patient’s stay, increase the risk of sepsis, and even result in death.
Errors by Near Miss
A near miss is a dispensing error discovered and intercepted before reaching the patient. It means that the potential cause of harm does not result in actual harm. In healthcare, the clinician is often unaware that the near miss error has occurred. When discovered, reporting the near miss will help the organization identify the events leading up to the error, reducing the risk of future mistakes.
Provider Controls
Educating the patient and clinician is a key factor into medication safety and error prevention. The Centers for Disease Control (CDC) website recommends that clinicians adhere to the “5 Rights” of medication administration: right patient, right drug, right dose, right route, and right time. Consider the following best practices.
- Become familiar with what is prescribed and dispensed. Know high-risk medications and use necessary precautions. Use generic drug names when possible.
- Medication reconciliation is essential to the administration and patient care process. To help avoid drugto-drug interactions, ensure all currently used and/or prescribed medications have been listed, including over-the-counter (OTC) drugs, herbal supplements, and medicated lotions.
- Provide the patient and family with educational handouts on the medications they are taking and assess their level of understanding, adjusting verbiage accordingly.
- When the patient/family is self-administering medication, conduct a detailed demonstration of administration and ask for a return demonstration. Provide education on potential side effects of any new medications and reminders of side-effects of current medications. Educate the patient/family on preparing a daily pillbox and the importance of medication adherence. Help them create a log of when the
medication was taken as well as the associated outcome.
- Create an environment of safety. Ensure there are no interruptions while administering/preparing medication and avoid distractions.
Diversion
Medication diversion is the misuse or theft of controlled substances and medications used for pain management. Diversion frequently occurs in healthcare settings, including assisted living facilities (ALF), skilled nursing facilities (SNF), and hospice in-patient units (IPU/homecare), and it often goes undetected. Diverters may be patients, family members, and healthcare workers. Medication diversion can lead to inadequate pain relief, inaccuracies in documentation of care, exposure to infectious diseases from contaminated drugs and needles, as well as impaired healthcare worker (HCW) performance (Berge et al., 2012).
In hospice and home health, drug diversion is not unheard of as the patient services are likely in their home settings, and the patient and/or families are responsible for their medication management. Medication diverters often attempt to obtain medication under false pretenses, which may include illicit drug sales and/ or feeding their personal addiction. Diversion due to addiction puts the patient at risk of harm and presents regulatory and legal risks to the organization.
Provider Controls
In these settings, adherence to medication policies and procedures, including patient accountability, is crucial. An incorrect patient action can cause a patient to take medication inappropriately or not as prescribed. Consider the following best practices.
- Provide comprehensive training to staff on medication diversion, including the risks and consequences, and educate staff on company policies and procedures.
- Train staff on recognizing potential signs of medication diversion, such as unexplained discrepancies in medication records, frequent medication errors, or unusual behavior among colleagues. Training should emphasize the importance of reporting these signs promptly.
- Conduct and document medication counts during each visit to help minimize diversion and increase quality of care. This procedure will allow the clinician to identify an issue and ensure the patient has adequate supplies of their medication.
- Review the storage and security of medications and ensure there are internal pharmacy controls for administering and prescribing controlled substances. Additionally, review and monitor medication returns, disposal of medications, and wasting of medication. Ensure witnesses are present for these action items.
Summary
Medication safety must be a priority for healthcare providers. Medication errors can result in harm to the patient, unnecessary hospital admissions, increased length of hospital stays, and significant liability risks to the organization. Healthcare providers must take precautions to prevent errors in the administration, omission, and diversion of medications, as well as the near miss of a medication error. Ensure that assessment and evaluation of drug administration, client education, and documentation are present. Additionally, errors should
be reported according to the organization’s policies and procedures.
References
- Berge, K. H., Dillon K. R., Sikkink, K. M., Taylor, T. K., & Lanier, W. L. (2012). Diversion of drugs within healthcare
facilities, a multiple-victim crime: patterns of diversion, scope, consequences, detection, and prevention. Mayo
Clinic Proceedings 87(7), 674-82.
- Centers for Disease Control & Prevention (CDC). (n.d.). Medication Safety Basics. Retrieved from: https://www.
cdc.gov/medication-safety/about/index.html
- MacDowell, P., Cabri, A., and Davis, M. (2021). Medication Administration Errors. Patient Safety Network.
Retrieved from: https://psnet.ahrq.gov/primer/medication-administration-errors
- Rasool, M. F., Rehman, A. U., Imran, I., Abbas, S., Shah, S., Abbas, G., Khan, I., Shakeel, S., Ahmad Hassali, M.
A., & Hayat, K. (2020). Risk Factors Associated With Medication Errors Among Patients Suffering From Chronic
Disorders. Frontiers in public health, 8, 531038. https://doi.org/10.3389/fpubh.2020.531038
