Medication Errors: A Case-Based Review

Abstract

Every day, nurses are inundated with alerts warning of potential medication errors via system safeguards. Even though error-reduction systems are in place, human errors still occur. Clinicians learn of medication errors and attempt to identify gaps in the medication administration system, but they rarely have the opportunity to delve into the root of the error. Nurses rightfully question how errors occur and how they can be prevented. Because of this, clinicians need to develop the skills necessary to recognize and reduce the risk of errors and to better identify errors before they reach the patient. This column provides an overview of medication errors and case reviews, followed by a discussion of relevant strategies for preventing medication errors.It may be said that our brains are naturally wired to make errors because of our propensity to be creative.1 We depend on our thought processes to stop an error from occurring, but our thought processes can also cause risk or provide an opportunity for error. The thought process can be broken down into 2 steps: planning and execution. Errors can occur in either or both steps. Planning errors are mistakes caused by a deficiency in knowledge or a misapplication of a rule. Mistakes occur, for instance, when training is deficient or providers are involved in nonroutine tasks. Errors in execution occur because of slips or lapses that lead to incorrect implementation of a plan.2 A slip is failure related to attention such as an interference error, whereas a lapse is a failure in memory such as an omission.2 Both planning and execution errors occur with medication use; therefore, how do we define a medication error?The Institute for Safe Medication Practices (ISMP) defines a medication error as any error occurring in the medication use process,3 a “preventable event that may cause or lead to inappropriate medication use or patient harm.”4 A medication error can occur as an error of commission (planning)—the act of doing something purposefully.5 An error of omission (execution) represents failure to take an appropriate step.5 Both types of error may lead to an undesirable outcome or have a significant potential for an adverse event. An adverse drug event is associated with harm related to the use of a medication. We know errors are made in the medication use process, but how extensive is the problem?The American Society of Health-System Pharmacists has outlined the more commonly observed medication errors in hospitals. These include prescribing errors, dispensing errors, medication administration errors, and patient compliance errors.6 The medication use process has multiple risk points for errors. The ISMP has identified 10 key elements of medication use (Table 1).7 The goal is to strengthen these elements to reduce the risk of medication errors and patient harm.7In 1999, the Institute of Medicine (IOM) published a report that sounded a warning bell for the health care industry.8 The IOM estimated that between 44 000 and 98 000 people die every year as a result of medical errors. This is equivalent to 2 jumbo jet crashes every week. Half of those medical error deaths were due to medication errors.8 The IOM concluded that medication errors led to increases in mortality, treatment cost, and patients’ length of stay.8 Earlier studies show that hospital medication errors occur in approximately 3% to 6.9% of inpatients.9,10 Further studies show that rates are actually higher than cited in the 1999 IOM report because of underreporting, with the numbers of preventable adverse drug events reaching 380 000 to 450 000 annually.11 Although the rate is difficult to estimate, various rates of medication errors have been identified in observational studies.It is estimated that 1.5 million patients are harmed annually in the United States as a result of medication errors.11 Most recently, in an 18-month study12 of 6 Massachusetts community hospitals, it was found that 3.8 million patients were affected