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Medication Errors: Ramifications and Prevention

Ellie Weiser

Countless medication errors occur per year, between prescribing and dispensing errors. These errors not only cost billions of dollars to rectify, but they also lead to adverse events and even death.


It is estimated that in the United States alone that 7,000 to 9,000 people die each year due to medication errors, and the total cost of these errors exceed $40 billion each year.

There are multiple reasons drug errors occur including failure to communicate the drug order, illegible handwriting, wrong drug selection, confusion over similarly named drug, or lack of checking patient identifiers.


What is a Medication Error?


According to The National Coordinating Council for Medication Error Reporting and Prevention, medication errors are defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer”.


In the hospital setting, medication errors can be quite high, accounting for about 19% of all injuries. When these events occur among hospitalized patients there is an increased risk for morbidity and mortality, as well as prolonged hospitalization, leading to higher costs of care.


How to Prevent Medication Errors?


Because of the high incidence of medication errors, prevention is key in order to avoid adverse outcomes. Use of computerized physician order entry as well as the electronic medication administration record are just a couple of ways that drug errors can be reduced as they create a “double checking” system allowing the clinician to making sure they are ordering or dispensing the correct medication.


However, even with all of the latest computerized software, errors can still occur, reminding clinicians that they still need to err on the side of caution when ordering and dispending medications to patients. Double checking diagnosis, drug to drug interactions, and dosing are all important when ordering drugs. Ensuring the use of the “Five Rights” when administering medications is even more crucial as the last line of defense between a potential error and the patient.


Over my years as a clinician I have seen how frequently medication errors can occur, and even with all of the interventions in place still do happen. Checking, double checking, and using critical thinking are all extremely important when handling and dispensing medication to avoid potential adverse outcomes.


If you have a case involving a medication error, contact Weiser Nurse Consulting. We can help review the case and identify possible breaches in standard of care.


Tariq, R.A., Vashisht, R., Sinha, A., & Scherbak, Y. Medication dispensing errors and prevention. 2021 Jul 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 30085607.


Zhu, J, & Weingart, S.N. (2021). Prevention of adverse drug events in the hospitals. https://www.uptodate.com/contents/prevention-of-adverse-drug-events-in-hospitals

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