The document discusses the multidimensional nature of medication errors, their types (prescribing, dispensing, and administration), and contributing factors such as human, system, and medication-related issues. Recommendations are provided for reducing these errors, including electronic prescribing, thorough communication, and proper training for healthcare professionals. It highlights the significant role of regulatory authorities, prescribers, pharmacists, and nursing staff in preventing errors and ensuring patient safety.

1. MEDICATION ERRORS
DETECTION AND MANAGEMENT
BY – DR. ANURAG SHARMA
JUNIOR RESIDENT
DEPARTMENT OF PHARMACOLOGY & THERAPEUTICS

2. DEFINITION
• Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in control of the healthcare professional,
patient or consumer.
• May occur at any time from the prescription to
consumption of the medicine.

3. • Problems & sources of medication errors are
multidisciplinary and multifactorial.
• Errors occur from –
a. Lack of knowledge
b. Unclear labelling of drug
c. Misidentification of patient
d. Mental lapses or
e. Verification errors

4. • FACTORS CONTRIBUTING TO MEDICATION
ERRORS
1. Human-related
2. System-related
3. Medication-related

5. HUMAN RELATED FACTORS
PROVIDERS PATIENTS
1. Over-worked 1. In a hurry
2. Under-trained 2. Health literacy level
3. Competence 3. Donot understand the
medication/use
4. Distracted 4. Trust Providers to not make
mistakes
5. Illness
6. Stressed

6. SYSTEM RELATED FACTORS
1. Lack of Communication
2. Poor workflow
3. Disorganized workspace
4. Lack of supervision

7. MEDICATION RELATED FACTORS
1. Look-alike/ Sound-alike medications
2. Multiple dosage forms and strengths

8. TYPES OF MEDICATION ERRORS
1. Prescribing Error
2. Dispensing Error
3. Administration Error

9. Prescribing errors
1. Incorrect drug
selection for a patient
2. Errors in quantity
and indication
3. Prescribing
contraindicated
drug

10. • Factors contributing prescribing errors -
i. Lack of knowledge of the prescribed drug, dose, patient details
ii. Illegible handwriting
iii. Inaccurate medication history taking
iv. Confusion with the drug name
v. Inappropriate use of decimal points
vi. Use of abbreviations
vii. Use of verbal orders

11. • Reducing Prescribing errors -
1. Electronic prescribing reduces errors due to
illegible handwriting
2. Computerized physician order entry system
eliminates need for transcription orders by
nursing staff

12. Dispensing Errors
• A dispensing error is a discrepancy between a
prescription and the medicine that the
pharmacy delivers to the patient on the basis
of prescription.

13. • Most Prevalent Dispensing Errors –
1. Dispensing incorrect medication, dosage strength, or
dosage form
2. Dosage miscalculations
3. Failure to identify drug interactions or
containdications

14. • Reducing Dispensing errors –
1. Ensuring a safe dispensing procedure
2. Separating drugs with similar name or appearance
3. Automated medication dispensing system
4. Unit dose medication dispensing

15. • Example of Dispensing Error
A Physician writes an order for primidone for a patient with
seizure disorder. Misreading the physician’s handwriting, the
pharmacist mistakenly dispensed the prednisone. For 4
months, the patient receives prednisone alongwith his other
seizure medications causing steroid-induced diabetes. The
diabetes goes unrecognized, and patient dies from Diabetic
Ketoacidosis because the drug was LASA drug that lead to
Dispensing Error.

16. LOOK ALIKE SOUND ALIKE (LASA)
• Existence of confusing drug names is one of
the most common causes of medication error
• With thousands of drugs currently in market,
potential for error due to confusing drug
names is significant

17. Examples of LASA Drugs
BRAND NAME (GENERIC NAME) BRAND NAME (GENERIC NAME)
1. BENZOL (DANAZOL) 1. BENZOLE (ALBENDAZOLE)
2. AMSAT (AMPICILLIN) 2. AMSET (AMLODIPINE)
3. ADCOM (TELMISARTAN) 3. ADCON (FLUCONAZOLE)
4. ALFLOX (NORFLOXACIN) 4. ALFOX (OXCARBAZEPINE)
5. DAZOLIC (ORNIDAZOLE) 5. DAZOLIN (SERTRALINE)

18. Administration Errors
• Discrepancy between drug received by patient &
drug therapy intended by prescriber
• Errors of omission- the drug is not administered
• Incorrect administration technique &
administration of incorrect or expired preparations

19. • Contributing factors for administration errors –
1. Failure to check patient’s identity prior to administration
2. Environmental factors such as noise, interruptions, poor
lighting
3. Wrong calculation to determine the correct dose

20. • Reducing administration errors –
1. Checking patient’s identity
2. Ensuring dosage calculations are cross checked
independently by another healthcare
professional before drug is administered
3. Ensuring medication given at correct time

21. Drugs commonly associated with Medication
errors
• Analgesics
 Unnecessary use of Opioids (over sedation of patient)
 Failure to monitor clinical parameters (HR,RR & BP), resulted in
major adverse outcomes related to opioid use
• Antibiotics
 Irrational use

22. • Anticoagulants
 Inadequate therapeutic dosing
 Failure to monitor blood levels
• Cardiovascular agents
 Errors due to overdose
 Failure to identify drug-drug interactions due to polypharmacy

23. • Diabetic Medications
 Overdose of hypoglycemic drugs (Insulin)
 Overenthusiastic patients trying to keep blood glucose levels within
normal limits
 This group of drugs signifies importance of patient education by
treating physicians

24. Six step approach by WHO for good
prescribing
1. Evaluate & Clearly define patient’s problem
2. Specify therapeutic objectives
3. Select appropriate drug therapy: P-drug & STEPS approach (Safety,
Tolerability, Effectiveness, Price & Simplicity)
4. Initiate therapy with appropriate details
5. Give information, instructions & warnings
6. Evaluate therapy regularly

25. Role of Regulatory Authorities
• Important role in preventing medication errors
• Review of drug labels & nomenclature greatly
enhances preventive strategies
• Public education by regulatory agencies improve
medication use
• Potentially confusing names to be rejected

26. Role of Prescribers/Physicians
1. Doctors should have knowledge of generic names & brand
names of available drugs in their local setting
2. Specify dosage form, drug strength & complete directions
on prescriptions
3. Using both brand name & generic name on prescription
4. Purpose of Medication
5. Legible Handwriting

27. Role of Pharmacists
• Refer back to Doctor if any confusion
• Basic knowledge of dosing regimens for commonly used
drugs
• Sticker of ‘ALERT’ can be used in areas where LASA drugs
stored
• In case of wrong prescription, Pharmacist should not
react in front of patient

28. Role of Nursing Staff
• Education & proper training is important in
reducing medication related errors
• Should be aware of correct storage
requirements for drugs
• Independent calculations of paediatric doses by
more than one person

29. REFERENCES
• Medication Errors: Causes & its prevention,
Singh I, Shafiq N, Malhotra S; Drugs Bulletin
Vol.XXXVI No. 2, April 2011
• British Journal of clinical pharmacology; 67:6,
2009