Medication errors

Although, strictly speaking, medication errors should come under the heading of clinical management, they account for such a high level of complaints, claims and patient safety incidents that they deserve separate mention. The four most common errors are:

• Wrong dosage.
• Inappropriate medication.
• Failure to monitor treatment for side-effects and toxicity.
• Communication failure between the doctor and patient.⁸

Underlying these are a myriad of causes (see Box 10). Most of the errors can be avoided by simple checking procedures and clear, open communication.

Box 10: Some causes of medication errors

• Badly-transcribed instructions.
• Illegible prescriptions.
• Miscalculation of dosage.
• Confusion between similar-sounding drug names or similar-looking packages.
• Clicking on the wrong drug in a drop-down menu.
• Prescribing contraindicated drugs. Not checking for potential drug interactions.
• Not reviewing repeat prescriptions.
• Failure to follow up/monitor.
• Failure to act on laboratory results.

When writing prescriptions

• Be sure that the treatment is indicated.  
• Check that the intended drug is not contraindicated and that the patient does not have a history of adverse reactions to it. Ensure that it will not interact with the patient’s other medication and warn the patient about any potential interactions with over-the-counter remedies. 
• If issuing a hand-written prescription, write legibly, taking special care if the drug name could easily be confused with another – use capital letters and give the generic rather than trade name. 
• If you’re not sure which of two similar-sounding drugs you should be prescribing, check with a senior colleague and confirm the correct spelling in a national formulary.
• Write clear and unambiguous instructions for dosage, frequency and route of administration.  
• Note the prescription and any other relevant information (eg, warnings given to the patient) in the medical record. 
• Ensure that the patient is aware of what is being prescribed, and why.

Checking procedures

• If you are calculating a dose using a formula (eg, mg/kg or µg/m²), ask a competent colleague to check your arithmetic and placing of decimal points. Be particularly careful when calculating the dose  of an unfamiliar drug.
• If a pharmacist or nurse questions a drug order or prescription, check it carefully – many problems are prevented by helpful interaction between colleagues.
• Always read the label on the bottle or vial before administering a drug or other substance, such as water for injection.
• Establish the identity of the patient and double-check the prescription before administering medication.

Communication

• If you are prescribing medication to be administered by other members of the healthcare team, issue clear and unambiguous instructions – answer fully any queries they may have.
• Make sure that relevant members of the communication net (see page 21 of PDF) know what drugs the patient is taking and that they are told promptly about any changes.  
• Document the administration of medication (name, time, dose) in the appropriate place in the medical records.

Systems

Ideally, all involved staff should have input in designing appropriate administrative procedures – they are best placed to identify problems and, if they feel a sense of ownership of the procedures, they are far more likely to adhere to them. Even if you already have systems in place, it is worth subjecting them to regular review to see if they’re working as planned or can be improved. This is also an opportunity to remind staff how important it is to follow the procedures laid down. Important aspects to consider are: 

• Reviewing repeat prescriptions.
• Reviewing laboratory reports and acting on identified abnormalities.
• Flagging up drug allergies.
• Alerting relevant members of the communication net to prescription changes.
• Reporting medication errors – this should be encouraged by taking a non-punitive attitude that focuses on the causes rather than the culprit.