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 NPSA, which is to be abolished in its current form, has operated a National Reporting and Learning Service (NRLS) that received about 5,000 reports a month about patient safety incidents related to medication. In an analysis of medication-related patient safety incidents and clinical negligence claims that occurred between January and December 2007,⁸ incidents that resulted in serious harm or death of the patient (see Box 12 for examples) could be attributed to one of the following eight error types:

• Unclear/wrong dose or frequency
• Wrong medicine
• Omitted/delayed medicines
• Contraindicated medicine
• Adverse drug reaction
• Allergy to medicine
• Wrong route
• Mismatching patients.

According to the US organisation, the Institute of Medicine⁹, the first and most fundamental step in preventing medication errors is to work in partnership with patients:

Providers should take steps to educate, consult with, and listen to the patients

“Patients should understand more about their medications and take more responsibility for monitoring those medications, while providers should take steps to educate, consult with, and listen to the patients.

“To make this new model of health care work, a number of things must be done. Doctors, nurses, pharmacists and other providers must communicate more with patients at every step of the way and make that communication a two-way street, listening to the patients as well as talking to them. They should inform their patients fully about the risks, contraindications, and possible side effects of the medications they are taking and what to do if they experience a side effect.”

Institute of Medicine, Preventing Medication Errors, Report Briefing (2006), p 2.

When writing prescriptions

Write clear and unambiguous instructions for dosage, frequency and route of administration, avoiding abbreviations and leading decimal points

• 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 medicines.
• 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, avoiding abbreviations and leading decimal points.
• 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. Use patient information leaflets to augment your verbal instructions, and be particularly careful to warn patients about possible side-effects, adverse drug interactions (including herbal medicines), or potentially dangerous activities, such as driving while taking drugs that induce drowsiness.

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.

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 Administrative procedures page) know what drugs the patient is taking and that they are told promptly about any changes.
• Ensure that you are aware of policies regarding verbal prescriptions (double-checking and documenting patient’s name, medication, dosage and route of administration).
• Document the administration of medication (name, time, dose) in the appropriate place in the medical records.