QJM Advance Access originally published online on May 20, 2009
QJM 2009 102(8):513-521; doi:10.1093/qjmed/hcp052
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Medication errors: what they are, how they happen, and how to avoid them
From the Department of Primary Health Care, Rosemary Rue Building, Old Road Campus, Headington, Oxford OX3 7LF, UK
Address correspondence to J.K. Aronson, Reader in Clinical Pharmacology, Department of Primary Health Care, Rosemary Rue Building, Old Road Campus, Headington, Oxford OX3 7LF, UK. email: jeffrey.aronson{at}clinpharm.ox.ac.uk
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Abstract |
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A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration). They can be classified, using a psychological classification of errors, as knowledge-, rule-, action- and memory-based errors. Although medication errors can occasionally be serious, they are not commonly so and are often trivial. However, it is important to detect them, since system failures that result in minor errors can later lead to serious errors. Reporting of errors should be encouraged by creating a blame-free, non-punitive environment. Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm. In balanced prescribing the mechanism of action of the drug should be married to the pathophysiology of the disease.