Medication safety in preventing human error

We have so far seen how clinical guidelines and checklists help to preserve patient safety. In this post, we will explore the measures that help to prevent medication errors. A medication error is defined by Robin Ferner, in a paper titled The epidemiology of medication errors: the methodological difficulties, as ‘failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’.  Michael Schachter, in a paper titled The epidemiology of medication errors: how many, how serious?, further pointed out that medication errors are ‘frequent and often avoidable‘, and they represent ‘a major threat to patient safety’.


The pervasive dangers of medication errors were stressed in a report titled Building a safer NHS for patients: Improving Medication Safety; there, the United Kingdom Chief Pharmaceutical Officer (UK CPO) noted that all the three components of the medication process – prescribing, dispensing, and administration – are associated with patient safety risks. The report went on to identify several factors that compromise medication safety amongst which are:

    • Fatigue
    • Heavy workload
    • Inadequate knowledge of the patient or the drug
    • Miscalculation of the dose
    • Illegible handwriting
    • Confusion of drug names and packaging
    • Wrong route drug administration
Happy Pills Prescription. Philippa Willitts on Flickr.

Sharon Edwards and Sue Axe also explored the causes of medication errors in their paper titled The 10 ‘R’s of safe multidisciplinary drug administration. They reported that most ‘fatal and serious harm‘ are caused by unclear prescriptions and dosing errors. Based on this, the authors listed the 10R requirements for the safe administration of medications amongst are:

    • The right patient
    • The right drug for the patient and the condition
    • The right dose
    • The right route
    • The right time
    • The right knowledge and understanding of the drug
    • Review of the drug response
Spilled out. Ajay Suresh on Flickr.

The UK CPO report also made recommendations to prevent medication errors. Some of these are:

    • Using electronic prescribing systems
    • Applying information technology in drug prescribing, dispensing and administration
    • Establishing ‘formal dispensary checking systems and procedures’
    • Sharing patients’ treatment plans with all professionals involved in the patient’s care
    • Training and competency assessment in all stages of the medication process
    • Instituting ‘clear drug administration procedures in all settings where medicines are given’
    • Double checking of drug dose and route in high risk situations
    • Involving patients and their carers in cross-checking drug doses
Medication. AL.Eyad on Flickr.

Further recommendations to minimise the risk of medication dose errors were made in the book Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, and these included:

    • Using preprinted order forms
    • Avoiding the use of abbreviations
    • Avoiding leading and trailing zeros: 0.2 and 2.0
    • Prescribing using dose weight and not number of tablets
    • Standardising dose options
    • Standardising administration times
    • Using allergy wrist bands
Time to take medication conception. Marco Verch Professional Photographer on Flickr.

In the next post we will look at risk communication in preventing human error.

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