Medication Errors Frequently Asked Questions

What are medication errors?
Where do medication errors originate?
What are some of the causes and contributing factors that are involved in medication errors?
What products are frequently involved in medication errors?
What can hospitals and health systems do to help prevent errors?

Q. What are medication errors?

A. The National Coordinating Council for Medication Error Reporting and Prevention¹ (NCC MERP) defines a medication error 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 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, nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use."

Q. Where do medication errors originate?

A. Medication errors can and do originate in all stages of the medication use process, which can include the writing of the prescription order, fulfilling the order in the pharmacy, preparing the medication dose at the nursing station, or administering the medication at the patient's bedside.

Q. What are some of the causes and contributing factors that are involved in medication errors?

A. Causes of errors include calculations, use of abbreviations and leading or trailing zeros. Some major contributing factors that cause medication errors are distractions (situational), workload increase (resources), and staffing issues. Staffing issues encompass inexperienced staff, floating and temporary staff, and insufficient staffing. Also important is the current shortage of health care professionals and allied health personnel, which has a potential impact on patient safety.

Q. What products are frequently involved in medication errors?

A. There are several products that are most frequently involved in medication errors according to the MEDMARX® data reports from 1999 to 2002. These products include insulin, warfarin, heparin and albuterol.

Q. What can hospitals and health systems do to help prevent errors?

A. It is important for hospitals and health systems to encourage and reward reporting and to adequately resource efforts to identify and analyze errors. Most important, however, is to acknowledge that medication errors are systemic flaws within the process and with the technologies employed in the medication use continuum. Hospitals and health systems should promote active involvement through leadership in the continual monitoring of errors and the long-term commitment to error elimination.

¹The National Coordinating Council for Medication Error Reporting and Prevention (Council) or NCC MERP, was founded in 1995 to promote the reporting, understanding and prevention of medication errors. The Council comprises health-related organizations, societies and agencies, including medicine, pharmacy and nursing groups, consumer groups, standards-setting and federal regulatory bodies, and manufacturers. The Council's goals are to examine and evaluate the causes of medication errors; increase awareness of medication errors and methods of prevention throughout the health care system; recommend strategies relative to system modifications, practice standards, and guidelines; stimulate development and use of medication error reporting and evaluation systems; and stimulate reporting to a national system for review, analysis, and development of recommendations to reduce and prevent medication errors.