Pharmaceutical Press shares effective practices for reducing medication errors
Medicines are the most common therapeutic intervention in healthcare, and they have now become much more complex. Although patients benefit considerably as a result of living longer and better-quality lives, many experience significant harm due to mistakes or errors in how medicines are used. Medication errors occur frequently in health systems around the world, and, according to the World Health Organization (WHO), nearly 50% of preventable harm to patients globally is due to inappropriate use of medicines and other treatments. A quarter of this preventable harm can be severe or even life-threatening.1,2
Even when errors are not harmful or severe, they can drive the cost of care up, and the quality of care down.1 Fortunately, with greater awareness of the scale of the problem, there is now a focus on ensuring a culture of safety in health systems. With the right education, policies, prescribing tools, and reporting and learning systems, errors can be minimized and patients protected.
What are the most common types of medication errors?
Most studies refer to five main types of error, namely those related to prescribing, transcribing, preparation or dispensing, administration, or monitoring. Aronson also noted that errors could occur during the medicine manufacturing process, for example, when the packaging is incorrectly labeled, or adulterants are introduced.3
Preventing medication errors
Medication errors are a multifaceted problem, there is no one size fits all solution. Rather, tailored approaches to understanding and mitigating the risks are required. Improved systems can help reduce error rates, such as electronic prescribing and automated dispensing. Reporting all drug errors and near misses, regardless of whether the patient came to harm, and having processes to investigate and analyse the data is crucial. It is only by building the baseline evidence that health systems can better understand how errors occur, and how to prevent them.
“Use of medicines has increased because of increased adherence to disease-based guidance. The increase in use also results, however, in increased hazards, errors, and adverse events associated with medicines, which can be reduced or even prevented by improving the systems and practice of medication,” WHO, Medication Without Harm, 2023.1
A culture of safety in the health system is necessary to ensure medication safety. With the necessary education, support, and tools, individual health professionals can do much to ensure safe practice.
The “5 Rights” of medication safety can help health professionals who administer drugs to avoid errors4
Best practice dictates that nurses and others carry out the following checks before giving a medication:
1. Right patient: Check the patient’s name using two identifiers (e.g., wristband, prescription) and the patient to identify themself if he or she is able.
2. Right drug: Check the medication label against what has been prescribed.
3. Right dose: Confirm the dose using current references, such as local protocols or the British National Formulary (BNF). If necessary, recalculate the dose and have a colleague check it.
4. Right route: Check the appropriateness of the prescribed route and confirm with the patient if they are able to take the medicine that way. For example, can they swallow a tablet or capsule?
5. Right time: Check the frequency of the prescribed medication and confirm when the last dose was given. Health professionals should use all available evidence-based resources to keep their knowledge and skills up to date.
MedicinesComplete
MedicinesComplete brings regularly updated medicine information and expert guidance on the use and administration of drugs together in one place, helping health professionals use medicines safely and avoid medication errors.
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Pharmaceutical Press
Trusted worldwide for providing evidence-based pharmaceutical knowledge to improve patient safety, we support health professionals to quickly and confidently make the most informed decisions on the safe and effective use of medicines. Our essential knowledge products are referred to daily by health professionals globally, across healthcare, academic and research settings and relied on by many commercial organisations to operate their businesses. As the Royal Pharmaceutical Society’s Knowledge Business, we invest our resources into creating world-class tools that promote best practice in medicines use, which means health professionals can quickly and confidently make the most informed decisions.
REFERENCES
1. WHO. (2023). Medication without harm. Available at: https://iris.who.int/bitstream/handle/10665/376212/9789240062764-eng.pdf. Last accessed: 22 April 2024.
2. Panagioti M., Khan K., Keers R.N., Abuzour A., Phipps D., Kontopantelis E., et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: Systematic review and meta-analysis. BMJ. 2019;366:I4185. doi: 10.11136/bmj.I4185.
3. Aronson, J. K. (2009). Medication errors: what they are, how they happen, and how to avoid them. QJM: An International Journal of Medicine, 102(8), 513-521.
4. Hanson, A., & Haddad, L. M. (2022). Nursing rights of medication administration. In StatPearls [Internet]. StatPearls Publishing.
