Medication Errors: A Review of Classifications

Medication errors: What is the pharmacist’s role?

C’est pire qu’un crime, c’est une fauteCharles Maurice de Talleyrand-Perigord (attributed)The error that Talleyrand is said to have considered worsethan a crime was Napoleon’s order to execute the Ducd’Enghien in 1794.The saying has also been attributed toJoseph Fouche, Bonaparte’s Minister of Police (later to bethe Duc d’Otrante) and to Antoine Boulay de la Meurthe (adeputy in the corps legislative). But whoever said it, itbetokens an attitude that the end justifies the means.And while one would not recommend breaking the law inorder to avoid medication errors, one should certainlystrive to avoid them as assiduously as one would refrainfrom committing a crime.A Pubmed search for the terms ‘medication errors’ or‘prescribing errors’yields nearly 8000 hits. [In contrast‘sur-gical errors’ yields about 100 hits – do surgeons not makeerrors?] And there is evidence that deaths from medicationerrors have been on the rise [1].This issue of the

Análisis descriptivo de los errores de medicación notificados en atención primaria: aprendiendo de nuestros errores

Medication errors (MEs) by caregivers at home are a cause of morbidity and mortality, shortly after discharge from the hospital. The objective of this study was to determine the rate and types of MEs at the homes of children discharged from a hospital in Ghana and to explore the factors associated with these errors. This was a cross-sectional study of infants and children discharged from the hospital to review medication administration practices. Caregivers of children discharged from the hospital after at least 24 hours of admission were interviewed at their homes about medication administration practices. The study assessed potential harm associated with MEs made by caregivers using the Harm Associated with Medication Error Classification tool. The Least Absolute Shrinkage and Selection Operator regression were used to identify the variables associated with MEs. A total of 95 children (mean age: 28.6 months, 52.6% female) and their caregivers were included. Overall, 65 (68.4%) children experienced one or more MEs. Out of a total of 232 medications reviewed, 102 (44.0%) (95% CI: 37.6-50.4) were associated with a ME. The top two errors, wrong time errors and errors in the frequency of dosing were, 45.1% and 21.6%, respectively. Understanding the information on the disease condition being treated and the medicines dispensed was associated with committing fewer MEs. The number of medicines prescribed was associated with a higher likelihood of MEs. Out of 102 MEs, 48 (47.1%) were assessed as posing potentially no harm, 26 (25.5%) minor harm, 15 (14.7%) moderate harm, and 13 (12.8%) serious harm to the patients. Importantly, none of the MEs were assessed as posing potentially severe or life-threatening harm to the patients. MEs in children following discharge are high, and systems should be developed to prevent these errors.

Retrospective study of medication errors and their impact on the safety of the oncological patient

Hospitalized children are prone to experience harm from medication errors (MEs). Strategies to prevent MEs can be developed from identified malfunctioning practices and conditions in the medication use process. In this study, we aimed to identify MEs and potentially unsafe medication practices (PUMPs) in hospitalized children, and to assess the potential harm of these, using raters of different professions. A 1-week observation using an undisguised technique was conducted on four paediatric hospital wards. One observer followed ward staff during medication prescribing, preparation and administration. MEs and PUMPs were documented using field notes. Three raters including a physician, a nurse and a clinical pharmacist assessed the potential harm of each ME and PUMP using a six-point Likert scale. Agreement was analysed using Fleiss' Kappa. A total of 16 MEs and 809 PUMPs were identified involving a preparation and administration error rate of 8%. No actual harm to patients was observed during the study. Raters assessed the potential harm of 318 unique MEs and PUMPs. Only slight agreement was found (Kappa = 0.26-0.33). A 4-hour delay in the administration of intravenous cefuroxime received the highest harm score. Observations involving no information during prescribing and variations in medication preparation were considered potentially fatal for medications such as digoxin, morphine, enoxaparin and insulin. MEs and potentially unsafe practices and conditions may affect medication safety of hospitalized children. However, observed MEs did not result in any harm. The agreement among raters assessing the potential harm of observations was low. Alternative methods to determine the clinical relevance of errors are needed.

Background. 39 years old Betsy Lehman, which in 1994 took part in a clinical study, died because of the excessive infusion of cyclophosphamide (4 times higher dose). The mistake was revealed only in 10 weeks after the patient’s death. Now there is a Betsy Lehman Center of Patient Safety and Decrease of Medical Errors. According to the definition, medication error is an unintended failure in the drug treatment process that leads to, or has the potential to lead to the harm of the patient. In turn, wrong usage of the drug is an intentional misuse not in accordance with the instruction for medical usage (including, with some illegal aims). According to the statistics, only in USA medical errors harm 44,000-98,000 patients annually and cause the death of 7,000 patients.
 Objective. To define the main concepts of medical errors and methods of their avoidance.
 Materials and methods. Analysis of literature data on this topic.
 Results and discussion. Categories of medical mistakes include the mistakes of prescribing, of dispensing, of preparation, of administration and of monitoring. Retrospective analysis of the correctness of drug administration had revealed that the risk factors of mistakes included patient’s age <15 y. o. or >64 y. o., and a big quantity of administered drugs. Nurses with different professional experience equally often made mistakes; mistakes were more often during night shifts. Medical mistakes in oncology have some peculiarities. Namely, in oncology the drug dose often depends on the body surface and other factors; exceeded dose is accompanied by the high toxicity, and the insufficient dose – by the severe decrease of treatment effectiveness; anticancer treatment is accompanied by the administration of the big amount of additional drugs (antiemetics, hemopoesis stimulators, glucocorticoids, etc.). Analysis of chemotherapy of 1311 adult patients, which underwent the treatment in the university clinics of Valencia (Spain), revealed the mistakes in 17.2 % of cases. Mistakes in drug prescription were the most often (75.7 %). Similar French study revealed the mistakes in 5.2 % of cases, the majority of them (91 %) were also the mistakes in prescription (wrong choice of treatment regimen, incomplete prescriptions, inadequate doses). Such mistakes have not only medical, but also the social and economic consequences, including the increase of treatment cost. Meta-analysis of R. Ashokkumar et al. (2018) revealed that the frequency of medical errors in oncology, according to the different studies, was about 0.004-41.6 %. There is one more problem: because of the fear of punishment healthcare workers hide their errors, that’s why the small amount of errors may not be the real favorable parameter, but just a result of incomplete notification. Factors of medical mistakes appearance are divided into 3 groups: due to healthcare workers (training level, knowledge, physical and emotional condition), due to clinics administration (presence of treatment standards, communication quality, registration and analysis of error cases) and social (staff workload, time limitations, workplace organization, payment). With the aim of prevention of medical errors in oncology we must implement the treatment standards and local protocols, control technics of preparation and administration of anticancer drugs, widen the network of clinical pharmacists, use external drug compounding, thoroughly manage the medical documents, introduce electronic control systems and improve the communication between medical workers. Talking about legal aspects, concept of medical error does not have any legal consolidation. Literature includes about 70 its definitions. In case of a complaint of patient or his/her relatives healthcare workers will be asked such questions: whether the diagnostics of the patient was complete, whether the diagnosis was correct and timely made, what are the causes of the unfavorable outcomes, is there any direct causative link between healthcare workers’ actions and these outcomes, whether there was any standards’ violations. In general, vague criteria of standardization of medical care decrease the level of legal protection of both patients and healthcare workers.
 Conclusions. 1. Medical errors are quite often, but their exact incidence can’t be established. 2. Medical errors in oncology have some peculiarities because of the peculiarities of tumor treatment. 3. With the aim of prevention of medical errors in oncology we must implement the treatment standards and local protocols, control technics of preparation and administration of anticancer drugs, widen the network of clinical pharmacists, use external drug compounding, thoroughly manage the medical documents, introduce electronic control systems and improve the communication.

A call to action for anticoagulation stewardship

Medication error is a mistake in the prescribing process and a failure in the treatment process that has the potential to cause harm and can endanger patients. During the year 2024, 22 medication errors were found in the pharmacy department of Hospital X. Therefore, this study aims to identify the causes of the high incidence of medication errors in the outpatient pharmacy department of Hospital X. This research uses qualitative methods. Data were obtained from primary data through interviews and Focus Group Discussions with 10 informants. Interviews were conducted with the head of the pharmacy installation along with the pharmacy staff, the outpatient installation, and the director. In contrast, the FGD was conducted with the director, the head of the medical support field, and the head of the pharmacy installation. Next, the data is grouped based on themes. After that, root cause analysis is used to determine the main cause. The study results revealed 7 main factors influencing the high rate of medication errors, namely the lack of implementation of electronic prescriptions, causing doctors to still write manual prescriptions, overprocessing during input by pharmacy staff, incorrect screening and input by pharmacy staff, many new pharmacy staff, insufficient human resources in the pharmacy installation, and pharmacy staff who tend to hesitate and fear when making confirmations. The analysis results show that the main cause of medication errors is the lack of implementation of electronic prescriptions, while the use of manual prescriptions complicates the pharmacists' ability to interpret them. After the implementation of electronic prescriptions at Hospital X, the IKP rate became 0 (no incidents occurred) during the observation period. Research shows that medication errors often occur because pharmacy staff find it difficult to interpret prescriptions from doctors who still use manual prescriptions. Electronic prescriptions need to be implemented immediately, with the preparation of a time schedule, the system and procedures to be used, as well as socialization for doctors.

There is little longitudinal information about the type and frequency of harm resulting from medication errors among outpatient children with cancer. We aimed to characterize rates and types of medication errors and harm to outpatient children with leukemia and lymphoma over 7months of treatment. We recruited children taking medications at home for leukemia or lymphoma from three pediatric cancer centers. Errors were identified by chart review, in-home medication review, observation of administration, and interviews. Physician reviewers confirmed error (Fleiss' κ=0.95), harm (Fleiss' κ=0.82), and suggested interventions. Generalized linear mixed models with random effects were used to account for clustering by site. Among 131 children taking 1669 medications with 367 home visits, 408 errors were identified, including 242 with potential for harm and 39 with harm (1.0 harm per 1000 patient-days [95% CI, 0.1-9.8]). Ten percent of children were injured by errors and 42% had errors with potential for harm. Twenty-six percent of caregivers reported that miscommunication led to missed doses or overdoses at home. Children on >13 medications had significantly more serious medication errors than those on fewer medications (77% vs 61%; p=.05). Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%). In this longitudinal study, 10% children with leukemia or lymphoma experienced adverse drug events because of outpatient medication errors. Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering. In this longitudinal study, medication errors in the clinic, pharmacy, or at home among children with leukemia or lymphoma over a 7-month period were common, and 10% suffered harm because of errors. Children on >13 medications had significantly more serious medication errors than those on fewer medications (77% vs 61%; p=.05). Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%). Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering.

Background The ability of medical students to speak up before a medical error occurs is a timely and necessary interaction to prevent potential patient harm. As it may be crucial to improve patient safety, we explored how medical students react to a medical error and provided them appropriate training regarding speaking up about medical issues. Methods A quasi-experimental study was conducted in Taiwan involving 153 medical students who participated in a speaking-up simulation course. They were divided into two groups. The first group participated in a non-life-threatening scenario before the intervention, followed by a personalized debriefing session, then a life-threatening scenario after the intervention. The second group participated in a life-threatening scenario before the intervention, followed by a personalized debriefing session, then a non-life-threatening scenario after the intervention. Students also completed patient safety attitude survey. Results During the preintervention scenario, the overall medical students’ speaking-up rate to medical error was 45.1%. The speaking-up rate of medical students in life-threatening scenario was significantly higher than the rate in non-life-threatening scenario before the intervention (64.6% vs 24.3%, p < 0.001). After personalized debriefing, the speaking-up rate to medical errors was significantly improved both in life-threatening scenarios (95.9%, p < 0.001) and in non-life-threatening scenarios (100%, p < 0.001). Male medical students had significantly higher speaking-up rates than female students in life-threatening scenario (76.2% vs 51.4%, p = 0.02). On post-intervention surveys, students provided several reasons for their likelihood of speaking up or remaining silent during a medical error event. Conclusions Medical students’ rate of speaking-up to medical error was higher in a simulated life-threatening scenario than in a simulated non-life-threatening scenario. Faculty-led personalized debriefing can facilitate medical students’ adoption of communication strategies to speak up more in medical error events. Educators should also consider gender differences when they design effective assertive communication courses. Practice points Personalized assertive communication training could improve medical students speaking up behavior in the event of medical error. The medical students have a higher rate of speaking up in the life-threatening scenario compared to the non-life-threatening scenario. Male students had a higher rate of speaking up than females in the life-threatening scenario but not in the non-life-threatening scenario.

Analgesic-related medication errors can be a threat to patient safety. This study aimed to identify and describe medication errors that can cause serious adverse drug events (ADEs) related to analgesic use. This retrospective, observational, medicolegal study analyzed closed cases concerning complications induced by medication errors involving 3 commonly used analgesics: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and acetaminophen (AAP). Cases closed between 1994 and 2019 that were available in the Korean Supreme Court judgment database system were included. Medication errors were categorized using a classification system (developed by our group) based on the stage of drug administration. Clinical characteristics and judgment statuses were analyzed. A total of 71 cases were included in the final analysis (opioids, n = 30; NSAIDs, n = 35; AAP, n = 6). Among them, 43 claims (60.6%) resulted in payments to the plaintiffs, with a median payment of $86,607 (interquartile range, $34,554-$193,782). The severity of ADEs was high (National Association of Insurance Commissioners scale ≥6) in 88.7% (n = 63) of claims, with a total of 44 (62%) deaths. The most common types of ADEs associated with opioid, NSAID, and AAP use were respiratory depression, anaphylactic shock, and fulminant hepatitis, respectively. The most common recognized medication errors associated with opioid, NSAIDs, and AAP were inappropriate patient monitoring (n = 10; 33.3%), improper analgesic choice (n = 15; 42.9%), and inappropriate treatment after ADEs (n = 3; 50%), respectively. Our findings indicate that efforts should be made to reduce medication errors related to analgesic use to prevent permanent injury and potential malpractice claims.

The medication management pathway (MMP) outlines the medication journey from the decision to prescribe through to monitoring the outcomes. Medication errors (MEs) can occur at any point of the pathway. MEs in children may result in poor health outcomes; and as children are more vulnerable to dose calculation and administration errors especially in the ambulatory setting, this cohort may be at a higher risk of adverse outcomes. This review aimed to identify MEs in children and attribute them to the steps within the MMP for paediatric ambulatory patients. A systematic search of studies related to MEs in children was performed using MEDLINE, EMBASE and International Pharmaceutical Abstracts in the period from Jan 1991 to June 2011, using keywords pertaining to children, medication errors and ambulatory settings. Thirty articles met the review inclusion criteria and the findings of these studies were reported. Based on the MMP, 26 studies reported prescribing errors, 7 dispensing errors, and 12 administration errors. Twelve studies reported errors at more than one time point within the MMP; four studies at 2 stages and 8 studies at 3 stages. The most common types of the errors identified were dose errors which commonly occurred during prescribing, dispensing, or administration. Studies have highlighted that MEs occurring in children, with most of the errors reported at the prescribing stage. This could be a reflection of the studies' focus, and further work is needed to review errors occurring at other time points during the medication management cycle. Identifying where errors occur will contribute to the development of novel strategies to detect and prevent these errors in ambulatory settings.

We have previously described and analysed some terms that are used in drug safety and have proposed definitions. Here we discuss and define terms that are used in the field of medication errors, particularly terms that are sometimes misunderstood or misused. We also discuss the classification of medication errors. A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Errors can be classified according to whether they are mistakes, slips, or lapses. Mistakes are errors in the planning of an action. They can be knowledge based or rule based. Slips and lapses are errors in carrying out an action - a slip through an erroneous performance and a lapse through an erroneous memory. Classification of medication errors is important because the probabilities of errors of different classes are different, as are the potential remedies.

Background: Patient safety is one of the major issues which are concerned with the World Health Organization (WHO) and the medical community in developing and developed countries. Based on Studies, about 10 % of patients admitted in hospitals will be damaged. Objectives: The aim of this study was to evaluate patient safety climate among nurses and their roles for predicting medical errors. Patients and Method: Questionnaire responses were obtained from 122 nurses. The questionnaire comprised four parts included 20 items related to patient safety climate, 6 items to Organizational factors, 15 items to influential factors on the incidence of medical errors and overall level of patient safety. The relationship between patient safety climate and factors in medical errors was evaluated by regression analysis using SPSS 17 software. Results: According to the results, there was a negative relationship between patient safety climate and factors affecting the incidence of medical errors (β = -0.22, P < 0.05). Also, poor safety climate was established among nurses (average of less than 3.5). Conclusions: As the nurses play direct roles associated with family members and healthcare professionals for providing safe and quality, therefore full attention to the safety climate is recommended for reducing medical errors and improving patient safety. The quality of Interactions among therapeutic members and assessing patient conditions and full dominance on treatment process will be extremely effective in health care.