Errors in Medication Use

Errors in Medication Use: Prescription, Dosage, and Medication Management

Mistakes in medication use can occur at various stages, including prescription, dosage determination, solution preparation, drug dispensing, and treatment monitoring. Through careful analysis, many adverse events can be prevented by exercising caution and taking deliberate actions.

Medication errors are prevalent in healthcare settings. Recent studies in the United Kingdom have shown that 7-9% of hospital prescriptions were incorrect, with a significant portion attributed to junior doctors. Common errors in hospital medication prescriptions include missing doses, dosing errors, and prescription inaccuracies.

Some common errors in hospital medication prescriptions include:

  • Missing doses upon admission.
  • Inadequate dosage.
  • Excessive dosage.
  • Failure to specify dosage.
  • Missing doses upon discharge.
  • Incorrect directions.
  • Unnecessary medication duplications.
  • Incorrect drug naming for pharmacists.
  • Failure to specify maximum dosage.
  • Lack of patient instructions regarding maximum quantities of medication.
  • Lack of physician signature.
  • Contraindications to medication use.
  • Improper usage method.
  • Lack of usage indicators.
  • Incorrect instructions.
  • Using the medication for longer than necessary.
  • Failure to specify the method of use.
  • Unspecified start date of use.
  • Non-compliance with medication use requirements.
  • Incorrect daily dosage division.
  • Patient severe sensitivity.
  • Medication interactions.

These examples highlight some of the common medication prescription errors in hospitals.

It is increasingly encouraged for medical institutions to report “no-fault” errors in the medical environment for analysis, aiming to identify causative relationships using human factor theory and addressing them to prevent future disasters.

Unintended errors in physician prescriptions may occur due to incorrect actions resulting from a lack of knowledge, such as directing atenolol to a patient with severe asthma due to unawareness of contraindications. To mitigate these errors, physicians must undergo proper training.

Several factors influence the occurrence of errors in medication use:

Systemic Factors:

  • Duration of physicians’ and other staffs’ work.
  • Patient load.
  • Professional support and oversight from colleagues.
  • Availability of information (medical records).
  • Pharmacological model design.
  • Physician distractions (congestion).
  • Existence of decision support systems.
  • Routine checks.
  • Reports and case analyses.

Physician-side Factors:

  • Knowledge.
  • Clinical pharmacy principles.
  • Commonly used medications.
  • Common therapeutic diseases.
  • Knowledge of supportive system capabilities.
  • Skills (experience).
  • Thorough medication history collection.
  • Obtaining confirming information for prescriptions.
  • Patient communication.
  • Calculation skills.
  • Prescription writing.
  • Psychological guidance.
  • Ability to deal with risks and uncertainties.
  • Prescription oversight.
  • Routine checks.

When a medication error is discovered, physicians must take actions to ensure patient safety:

  • Conduct a clinical analysis and implement measures to minimize adverse effects (such as corrective therapy, organizing monitoring, leaving a record in the monitoring log, informing colleagues of the situation).
  • Report the error so that fellow physicians can learn from the experience and consider ways to prevent a recurrence of such incidents in the future.