Medication errors

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Medication errors have been known to, according to the Agency for Healthcare Research and Quality (AHRQ), account for approximately 1,000,000 medical errors per year. Of those, approximately 10% have resulted in death.

Medication Administration Errors (MAE's) have been defined as 'any deviation from the physician's medication order as written on the patients' chart' it has been broadened to 'mistakes associated with drugs and intravenous solutions that are made during the prescription, transcription, dispensing, and administration phases of drug preparation and distribution.' (2) They have also been associated with an estimated 7,000 deaths per year.


Medication Administration errors occur at several phases in the care delivery environment, are associated with a number of patient care stakeholders, including clinicians, ancillary staff and the patients themselves, and can be categorized into one of two categories; errors of omission and errors of commission.

Errors of omission

Errors of omission are often associated with drug-drug interactions, drug dosage errors, ambiguous prescribing instructions, etc.

Errors of commission

Whereas, errors of commission are associated with medications being delivered via the wrong route, at the wrong time, the wrong dose, wrong patient, etc. Errors of omission are typically associated with the ordering phase, while errors of commission are associated with every phase thereafter.

In many writings it is suggested that the implementation of Computerized Practitioner Order Entry (CPOE) with Clinical Decision Support (CDS) will mitigate medication errors. To some extent, this is true, but the implementation of CPOE w/CDS will only impact some of the errors occurring at the ordering stage and those errors that are initiated by the ordering clinician. These errors include checking for patient contraindications, drug interactions, and medication prescribing in accordance with established clinical guidelines.

Medication errors

Since medication errors are 'costly, common and clinically important'(1), the methods employed to mitigate them must consider the other stakeholders as well. Historically, nurses have borne the burden of 'being seen as incompetent and in need of remedial assistance.' (2)This attribution has been owed to errors in route administration, i.e. 'enteral formulas administered parenterally, oral medications administered intrathecally, IM injectibles administered via I.V', etc. (4) These MAE's account for 38% of the reported medication errors, while errors at the ordering phase account for 39% of medication errors.(2) Because the systems associated with reporting MAE's are viewed as punitive, many clinicians don't report errors, which do little to mitigate these errors from occurring again. It is important to implement systems that are used as non-punitive educational tools as they are better received in the practice environment.

Because patients are not 'passive recipients of care', (3) they too play a role in the number of MAE's reported annually as well as the clinical and ancillary staff providing them care. In many instances patient MAE errors are owed to limited health literacy. This limited health literacy is associated with poorer health, medication non-adherence, and other problems. Since more patients want to partner with their health care providers to better understand their conditions and the progression associated therewith as well as their overall health outcomes, it is imperative they be brought into the fray. Patients will benefit from this greater understanding in a way such that they are more aware of and compliant with the medications needed to render their care.

Thus, the reliance on CPOE with CDS and any other single intervention will only have a partial impact on MAE's. To fully impact these errors and ensure increases in comprehensive health outcomes, the focus must be broadened to include not only CPOE w/CDS but also, error reporting systems and increases in patient education impacting and improving health literacy.


  1. Effects of Computerized Physician Order Entry and Clinical Decision Support Systems on Medication Safety, Kaushal Rainu, Shojania, Kaveh, Bates, David; 2003: 163; 1409-1413
  2. Medication Administration Errors: Understanding the Issues. McBride-Henry K, Fourer M, Australian Journal of Advanced Nursing. 2006:23;3; 33-41
  3. Examining the Adequacy of the 5 Rights of Medication Administration. MacDonald M. Clinical Nurse Specialist. 2010; 24;4: 196-201
  4. Wrong Route Errors. The Massachusetts Coalition for the Prevention of Medical Errors. Safety First. 1999: 1-4

Submitted by (Kimberly A. Goode)