review article
Medication Errors: A Preventable Problem
Kriti Malhotra*, Manoj Goyal**, Rani Walia†, Shafiqua Aslam‡
Abstract
Advancements in human healthcare are on an all time high. The treatment system is becoming hi-tech and sophisticated and
vulnerable to errors at the same time. Various disasters have occurred due to medication errors at different levels of healthcare
delivery. However, if a little bit of extra caution is observed by the various stakeholders these can be prevented largely.
Keywords: Mediclaim errors, healthcare delivery, malpractice litigation, word error, failure in communication
A
s we advance into an age of ever increasing
access to medical care, the susceptibility to
errors associated with medication is becoming
more common place. Patient safety, which plays a
prominent role in healthcare, has been highlighted in
recent times for the wrong reasons as increasing reports
of medication errors coupled with well-publicized cases
have raised public concern about the safety of modern
healthcare deliver.1 The goal of any drug therapy is
the achievement of defined therapeutic outcomes that
improve patient’s quality-of-life while minimizing
patient risk.2 But the process flow is vulnerable to a
number of ‘medication misadventure or error’ ranging
from patient information, drug information and its
proper communication; storage, standardization and
dispensing of drugs, environmental factors, staff
training and inbuilt quality controls.1
The National Coordinating Council for Medication
Error Reporting and Prevention 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 healthcare
professional, patient or consumer. Such events may be
*Junior Resident
**Assistant Professor
†Professor and Head
‡Professor
Dept. of Pharmacology, Maharishi Markandeshwar Institute of Medical Sciences and
Research, Mullana, Ambala, Haryana
Address for correspondence
Dr Manoj Goyal
Associate Professor
Dept. of Pharmacology, Maharishi Markandeshwar Institute of Medical Sciences and
Research, Mullana, Ambala, Haryana - 133 203
E-mail: dr_manojgoyal@yahoo.co.in
related to professional practice, healthcare products,
procedures and systems, including prescribing; order
communication; product labeling, packaging and
nomenclature; compounding; dispensing; distribution;
administration; education; monitoring and use”.3
Medication errors may be nobody’s baby, but when it
happens, it could well turn out to be everyone’s worry
and the reasons given for medication errors range
from silly to the downright serious.4 It is difficult to
determine the exact number or percentage of adverse
drug events and errors that occur in hospitals.
But it is possible, however, to say that medication
errors represent the third most frequent sentinel
events (11.4%). Examining the root cause of these
events - deficiencies in personal training and breakdown
in communications are documented.5
These errors may not be clinically significant on
many occasions but they have serious economical
consequences like extended hospital stays, additional
treatment and malpractice litigation.
According to the Institute of Medicine’s July 2006
report Preventing Medication Errors, medication errors
harm an estimated 1.5 million people in the United
States each year, resulting in upward $3.5 billion in
extra medical costs. If extrapolated to Indian setup
these figures would be much higher than expected. Put
into even more personal terms, every hospital patient
may be subjected to as much as one medication error
each day. These are shocking statistics for a largely
preventable problem.6
These errors can be lessened to a degree where the
patient doesn’t lose faith in the healthcare system.
Medication misadventure can occur anywhere in the
Indian Journal of Clinical Practice, Vol. 23, No. 1, June 2012 17
review article
healthcare system from prescriber to dispenser to
administration and finally to patient use.4
Prescriber/Practitioner
Focusing on the word error has drawn attention to
‘prevention’ and what can be done to minimize mistakes
and improve patient safety. Several definitions of error
have been put forward, but the one that seems to be
most appropriate in the context of medication errors is
‘an act that through ignorance, deficiency or accident
departs from or fails to achieve what should be done.’
What should be done is generally known as ‘the
five rights’: The right drug, right dose, right route,
right time and duration, and right patient.7 These
include prescribing errors, dispensing errors, medication
administration errors and patient compliance errors.8
They involve process breakdown in more than one
aspect of the system. Tragically, the misadventure
with drugs may result on behalf of the prescriber
aptly termed as the ‘prescribing error’-incorrect
drug selection in dose, dosage form, quantity, route,
concentration rate of administration or instructions for
use. Extending these, using abbreviations and zeroes
after decimal points creates additional unnecessary
uncertainties. Handwriting (the penmanship of many
physicians is notoriously atrocious) often leaves things
for interpretation.6 For e.g., using the abbreviation
‘U’ intended to mean ‘Units’ may be mistaken as
‘zero’ resulting in overdose. Spell out the word ‘units’
(e.g., ‘10 units’ regular insulin) instead. Similarly, ‘µg’
(micrograms) can be mistaken for ‘milligrams’ resulting
in 1,000-fold overdose. ‘SC’ or ‘SQ’ intended to mean
subcutaneous was mistaken as ‘SL’-sublingual when
poorly written. D/C (discharge, also discontinue)
was misinterpreted by discontinuing the drug
prematurely when D/C was meant to be ‘discharge’
versus discontinue. Ten-fold errors in the dosage and
strength of medications have occurred because there is
misinterpretation of the absence of a leading zero on
front of the decimal expression <1 (e.g., 0.5 has been
interpreted as 5) and the presence of a leading zero
in front of a number >1 (e.g. 5.0 has been interpreted
as 50). When possible, avoid the use of decimals (e.g.
prescribe 500 mg instead of 0.5 g). On an average,
doctors in developing countries spend <60 seconds
in prescribing medications and explaining the regime
to the patients according to WHO World Medicines
Situation that was released in April 2011. As a result
only half of the patients receive any advice on how to
take the medicine and about one-third of them don’t
know how to take the medicine immediately on leaving
18 Indian Journal of Clinical Practice, Vol. 23, No. 1, June 2012
the facility.9 There have been previous instances where
the prescriber forgot to mention the correct route of
drug administered and the ear/eye drops or the drugs
for intravaginal use were taken orally. This failure in
communication because of hurried, pressure-ridden
and at times hostile environment, has led to ineffective
treatment.
Due to lack of concentration (41%) because of too
many customers (53%) the practitioner tends to fail in
knowing the complete patient information (like about
patient’s allergies, other medications they are taking,
previous diagnosis, lab results, recent changes in renal
and hepatic function). The doctor should also take care
while giving verbal orders telephonically or bedside
that might be misinterpreted or may go undocumented.8
The prescriber should dictate verbal orders slowly,
clearly and articulately to avoid confusion. Special
caution is urged in the prescribing of drug dosages
in the teens (e.g. a 15 mEq dose of potassium chloride
could be misheard as a 50-mEq dose). The order should
be read back to the prescriber by the recipient (i.e., the
nurse or pharmacist). When read back, the drug name
should be spelled to the prescriber and, when directions
are repeated, no abbreviations should be used (e.g., say
‘three times daily’ rather than ‘t.i.d.’). A written copy
of the verbal order should be placed in the patient’s
medical record and later confirmed by the prescriber.
Nurse
By virtue of their direct patient-care activities and
administration of medications to patients, nurses -
perhaps more than any other healthcare providers - are
in an excellent position to detect and report medication
errors.
Extension of prescribing to staff other than doctors
cannot be held back just because the medical profession
has been unable to reorient its prescribing training
from an approach strong in theory but weak in safety
details.10 There has been some hesitation in reporting
medication errors in the nursing profession. Most
nurses fear humiliation from superiors and their peers
when reporting medication errors, although, it is the
nurse’s ethical and legal responsibility to document
such occurrences.11
Any failure to perform a system check within an
agency, the pharmacist and nurses must collaborate
on checking the accuracy and appropriateness of drug
orders before they are administrated to the patients.
Any incomplete order or illegible order where the
nurse is unsure of the correct drug, dosage or

administration method should be clarified with the
prescriber before the medications are administered.
Any medication with which they are unfamiliar, should
be cross-checked as it is considered an unsafe practice
on the part of the care takers. There are many avenues
by which the nurse can obtain medication knowledge
and updates. Current drug references should be
available on every nursing unit. Other medication
sources are available on the Internet and in nursing
journals. It is recommended that nurses familiarize
themselves with research on medical errors and how
they can be prevented.
Pharmacist
Another effective way to decrease medication errors is
to involve the pharmacist more actively in the patient’s
care.6 Pharmacists should participate in drug therapy
monitoring (including the following, when indicated:
the assessment of therapeutic appropriateness, medi-
cation administration appropriateness and possible
duplicate therapies; review for possible interactions;
and evaluation of pertinent clinical and laboratory data).
He should maintain medication profile for all patients
both inpatient and ambulatory to allow monitoring of
medication histories, allergies, diagnosing potential
drug interaction and adverse drug reaction (ADR).
He should also review the use of auxiliary labels and
use the labels prudently when it is clear that such use
may prevent errors (e.g., ‘shake well before use’, for
external use only’, ‘not for injection’, ‘crush the tablet’-
for sublingual use, etc.). Any ‘refilling-request’ of the
prescribed drug by the patient to the pharmacist should
correspond to the prescription and its date. He should
even discourage any telephonic prescriptions and in
emergency conditions the drug should be spelled back
with the directions of its usage to the practitioner. The
pharmacy department in any healthcare setup plays a
pivotal role and must be responsible for procurement,
distribution and control of all drugs used within the
organization with maintenance of adequate hours for
provision of pharmaceutical services.8
The Patient
One of the best preventive practices is to educate
the patient about their medications.11 Increased two-
way communication with patients can drastically
reduce medication errors. Patients should not just
listen to health professionals; they should be actively
engaged in their own healthcare, question prescription
recommendations and take responsibility for making
sure that caregivers know their health history. Patients
review article
(or their authorized caregivers or designees) have the
right to know about all aspects of their care, including
drug therapy and should feel free to ask questions
about any procedures or treatments received. Patients
should learn the names of the drug products that are
prescribed and administered to them, as well as dosage,
strengths and schedules.
It is suggested that patients should keep a personal list
of all drug therapy, including prescribed drugs, non-
prescription drugs, home remedies and medical foods.
Illiterate patients should make it a habit to verify the
dispensed drug with the doctor or any literate person
at home or in the neighborhood. They should also be
educated about the outcomes of pharmacotherapy by
written handouts and audiovisual teaching aids on
medication (at a level and language the patient can
understand) and contact information for healthcare
providers who should be notified in the event of an
ADR. After counseling from the authorized healthcare
provider about the appropriateness of the medication,
the patient should take all the medications as
directed.8
Manufacturer
It’s time that the manufacturing companies should also
join hands in the battle against this common enemy.
Poor designs with respect to drug product packaging
and labeling, as well as selection of inappropriate
or confusing nomenclature, have been identified as
factors that contribute to serious medication errors by
practitioners. Supply of improperly stored medications,
expired ones or overstocking are e.g. of common errors
that can be fixed by changing policies and procedures.
With more than 33,000 trademarked and 8,000 non-
proprietary medication names in the United States as
of 2004, it’s no surprise that many drug names sound
and look-alike. The search for a proprietary name is a
‘major problem’ for pharmaceutical companies, with
an increasing number of new preparations. The names
that ‘look or sound medically seductive’ are being
picked out. “Words that survive scrutiny will go
into a stockpile and await inexorable proliferation of
new drug”. We believe that there are enough brand
new words in this dictionary to keep us going for
years. We don’t yet know the proportion of names that
are unpronounceable.12 Similar sounding drugs e.g.
cerebyx versus celebrex versus celexa, create a lot of
confusion.
The first drug is used to treat seizures, the second to
relieve pain and inflammation, and the final one to treat
Indian Journal of Clinical Practice, Vol. 23, No. 1, June 2012 19
review article
depression; vastly different applications, shockingly
similar names! With a slip-up on a written prescription
or a misinterpretation at the pharmacy, a patient may
be taking something that is not needed and potentially
harmful. Nurses, pharmacists and others on the front
lines may easily confuse unclear prescriptions because
of the similarity in name or appearance. To minimize
confusion between drug names that look or sound
alike the FDA reviewed about 400 brand names a year
before they were marketed. About one-third were
rejected. For e.g. FDA has changed a drug after it was
approved in 2005 when the diabetes drug ‘Amaryl’
was being confused with the Alzheimer’s medication
‘Reminyl’, and one person died. Now the drug is
known as Razadyne. In the same way look-alike drugs
also contribute to these errors.
The labeling of ‘Heparin’ carpujects (for thrombo-
embolic phenomenon and ‘digoxin’ carpujects (for
congestive heart failure) were so similar that if the labels
were faced away from the reader, the carpujects could
be easily mistaken for one another. Another reporting
revealed that the size and the color of the Abbots
‘naloxone’ (for the reversal of opioid depression) 0.4
mg/ml and ‘tobramycin’ (for infection) 80 mg/2 ml vials
were similar. The vials were stocked near each other
in the picking station using the brand names ‘narcan’
and ‘nebcin’, respectively. During the code, it was
noticed that the crash card tray contained one vial of
‘tobramycin’ instead of ‘naloxone’.
Fortunately, the patient was not affected by this error.
Another incidence occurred, when a retail pharmacy had
reported a high potential for an error with ‘Metformin’
500 mg (antidiabetic agent) and ‘metronidazole’
500 mg (an antibacterial) both of which had similar
packaging and labeling and were supplied by the same
manufacturer. One facility also realized a ‘look-alike’
packaging between ‘labetalol’ (antihypertensive) and
‘doxapram’ (respiratory stimulant).13
Regulatory Authorities
Doctors in the Unites States are becoming concerned
about a coincidence that puts the travelers at a risk
of dangerous mix-ups in prescription medications.
Drugs in foreign countries sometimes have same
brand names as United States medications but contain
completely different ingredients. International mix-ups
are a new wrinkle in the long-standing problem for
drug name confusion.
For instance ‘Norpramin’ which is an antidepressant in
US is the name of an antiulcer drug in Spain. Flomax
for prostate disease has the same name as a pain
20 Indian Journal of Clinical Practice, Vol. 23, No. 1, June 2012
medication in Italy. And Vivelle, which in the US, is
a hormone for treatment menopause and osteoporosis
is a birth control pill in Austria. Dilacor (verapamil) is
used for irregular heart rhythm and hypertension in
Brazil, whereas the same brand name has a different
ingredient (i.e. diltiazam) (for blood-pressure control)
in US.
The studies say that more matches will be encountered
in Asia, South America and elsewhere. For travelers
who refill prescriptions abroad, brand name mix-up
could result in patients not getting a life-saving drug,
getting the wrong drug or suffering unexpected drug
interactions-especially the elderly person who take
multiple medications. Because there is no regulatory
body that keeps track of names globally, there is a
potential for more and deadlier cases to occur. The
problem of identical brand names potentially raises
bewilderment to a new level unless carried out in
earnest. The universe of drug names is huge and the
problem of mix-ups is only likely to grow until serious
measures by these regulatory bodies are taken to curtail
this.’13
Conclusion
Medicines cure, but they can also kill or cause severe
adverse reactions if a wrong medicine is administered
or if the dosage is wrong. Many disasters have
occurred due to the medication errors. Errors occur at
all levels of the medication use system, from prescriber
to the consumer through many intermediate levels.
These errors are not usually due to incompetence but
due to mostly preventable reasons. Ongoing quality
improvement programs for monitoring medication
errors are needed. Medication errors should be identified
and documented and their causes studied in order to
develop systems that minimize recurrence. Patient
education and participation in their own healthcare
decisions should be encouraged. Thus, it is the need of
the hour to give a wake-up call and all those concerned
should join hands to solve this gigantic problem!
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