Medication Errors - A Shared Responsibility

Elie Magdalani

What is a medication error?

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a "medication error" as follows: "A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

To simplify the meaning and make it clearer, these errors are classified according to the following "Wrongs…" as Wrong drug; Wrong route; Wrong dose; Wrong patient; Wrong timing of drug administration; or a contra-indicated drug for that patient; Wrong site; Wrong drug form; Wrong infusion rate; expired medication date; or prescription error.

Factors sharing the responsibility for medication errors

It’s a multifactor issue related to many factors:

1) Systems issues

The medication process in itself including prescribing, preparing and administering medications are a complex subsystem of a hospital. All are directed towards a variety of processes intended to ensure that patients receive appropriate treatment. However, if a problem arises in any and during these phases, it increases the possibility that a patient will not receive the correct medication, and consequently compromising his safety and health.

2) Professional issues

The issues that affect an individual professional’s practice are varied and of multifactor. Many researches conducted on medication errors frequently links errors to specific professional causes, focusing on individual practitioner’s attributes, skill levels and competencies (Preston 2004; Pape 2001; O'Shea 1999; Ernst, Buchanan and Cox 1991).

Others related contributing factors:

Miscommunication of medicines’ prescriptions as poor handwriting, confusion between drugs with similar names, similar packaging design, and confusion of their metric or other dosing units.

Lack of knowledge in pediatric patients, neonatal cases, and/or under treatment in the intensive care, calculating accurately the dosages based on their body weight is considered a life saving method. Here we consider the errors could be fatal when dealing with such age rangs (Oldridge et al 2004; Preston 2004; Schneider et al 1998; Segatore et al 1994).

Medication errors (ME) and pharmacovigilance

We can not separate pharmacovigilance from medication errors, pharmacovigilance had always been concerned with minimising the risks of adverse drug reactions and medication errors. Pharmacovigilance contributes to the detection and prevention of medication errors, collaboration of all parties will improve the quality of data collected, and enhancing patient safety.

A shared responsibility, in detecting medication errors depends on the collaboration of the patient, the pharmaceutical companies, the pharmacovigilance centers, and poison control centers.

Efforts are done to collect variable outputs of medication errors included in the pharmacovigilance ADRs report circulated by concerned pharmacovigilance centers and poison control centers locally and around the world.

How to minimise the possiblity of medication errors?

1. Drug Name Review, to prevent confusion,

2. Drug Labels, directed to Health Care Professionals,

3. Drug Labeling and Packaging, to prevent a similar-looking labeling and/or packaging,

4. Bar Code Label, excellent and sure method for dispensing medicines form the pharmacies,

5. Error Analysis, analyses of reports of medication errors included in the pharmacovigilance ADR reports will help in determining the cause, type, and methods of prevention of those errors, and

6. Public Education, using the available media tools (audio-visual and written).
In addition some recommendations are highly advised in order to use safely any medication prescribed by the physician. Here the main responsibility is directed to the patient to share in avoiding possible medication errors/mistakes. 

1. Find out the name of your medication 
If anything about the medication seems different, ask the pharmacist about it.
2. Ask questions about how to use your medication
Any possibly related question could be of a great help to minimise the risk of ME. 
3. Ask about the indications of your medication 
It's very important to understand your medication in order to use it correctly.
4. Keep the list of your medications with you at all times (if possible let a family member know also)
This should also include any dietary supplements, vitamins and herbals. In case of an emergency it will be very helpful.
5. Read medicine labels and follow directions 
Read the Patient Information Leaflet (PIL) that comes within the package insert for the HCP. Before you use any medication, you should know when to use it, how much to use, and how long to use it. 

Medication errors are preventable, they could be a life saving tool when occurring with the usage of some critical medicines in an accurate dosage and frequency. Medicines will never be deprived from ADRs or medication errors, but still their risk-benefit balance should always be towards the benefit which is for the patients.