Introduction – Medical errors are a serious public health problem and a leading cause of death in the United States. It is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event.
- By recognizing untoward events occur, learning from them, and working toward preventing them, patient safety can be improved.
- Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment.
Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers.
All providers know medical errors create a serious public health problem that poses a substantial threat to patient safety. Yet, one of the most challenging unanswered questions is “What constitutes a medical error?” The answer to this basic question has not been clearly established. Due to unclear definitions, “medical errors” are difficult to scientifically measure.
A lack of standardized nomenclature and overlapping definitions of medical errors has hindered data analysis, synthesis, and evaluation. There are two major types of errors:
- Errors of omission occur as a result of actions not taken. Examples are not strapping a patient into a wheelchair or not stabilizing a gurney prior to patient transfer.
- Errors of the commission occur as a result of the wrong action taken. Examples include administering a medication to which a patient has a known allergy or not labeling a laboratory specimen that is subsequently ascribed to the wrong patient.
Health care professionals experience profound psychological effects such as anger, guilt, inadequacy, depression, and suicide due to real or perceived errors. The threat of impending legal action may compound these feelings. This can also lead to a loss of clinical confidence.
- Clinicians equate errors with failure, with a breach of public trust, and with harming patients despite their mandate to “first do no harm.” Fear of punishment makes healthcare professionals reluctant to report errors.
- While they fear for patients’ safety, they also dread disciplinary action, including the fear of losing their jobs if they report an incident.
Unfortunately, failing to report contributes to the likelihood of serious patient harm. Many healthcare institutions have rigid policies in place that also create an adversarial environment. This can cause staff to hesitate to report an error, minimize the problem, or even fail to document the issue.
- These actions or lack thereof can contribute to an evolving cycle of medical errors.
- When these errors come to light, they can tarnish the reputation of the healthcare institution and the workers.
- Some experts hold that the term “error” is excessively negative, antagonistic and perpetuates a culture of blame.
A professional whose confidence and morale has been damaged as a result of an error may work less effectively and may abandon a career in medicine. Many experts suggest the term “error” should not be used at all. Due to the negative connotation, it is prudent to limit the use of the term “error” when documenting in the public medical record.
- However, adverse patient outcomes may occur because of errors; to delete the term obscures the goal of preventing and managing its causes and effects.
- Errors, no matter the nomenclature, typically occur from the convergence of multiple contributing factors.
- Public and legislative intolerance for medical errors typically illustrates a lack of understanding that some errors may not, in fact, be preventable with current technology or the resources available to the practitioner.
Human factors are always a problem, and identifying errors permits improvement strategies to be undertaken. In particular, blaming or punishing individuals for errors due to systemic causes does not address the causes nor prevent a repetition of the error.
The trend is for patient safety experts to focus on improving the safety of health care systems to reduce the probability of errors and mitigate their effects rather than focus on an individual’s actions. Errors represent an opportunity for constructive changes and improved education in health care delivery.
Governmental, legal, and medical institutions must work collaboratively to remove the culture of blame while retaining accountability. When this challenge is met, health care institutions will not be constrained from measuring targets for process improvement, including all errors, even with adverse outcomes.
- Healthcare providers want to improve outcomes while reducing the risk of patient harm.
- Despite provider best efforts, medical error rates remain high with significant disability and death.
- Preventable medical errors contribute substantially to healthcare costs, including higher health insurance costs per person expenses.
Only by health professionals working together will the cost and injury associated with medical errors be mitigated. The Joint Commission Patient Safety Goals The Joint Commission has introduced several patient safety goals to assist institutions and healthcare practitioners in creating a safer practice environment for patients and providers.
- Identify patient safety dangers and risks
- Identify patients correctly by confirming the identity in at least two ways
- Improve communication such as getting test results to the correct person quickly
- Prevent infection by hand-cleaning, post-op infection antibiotics, catheter changes, and central line precautions.
- Prevent mistakes in surgery by making sure the correct surgery is done on the correct body part; pause before surgery to double-check.
- Use device alarms and make sure that alarms on medical equipment are heard and checked quickly.
- Use medications correctly and safely, double-checking labeling and correctly passing on patient medicines to the next provider.
- Label all medications, even those in a syringe. This should preferably be done in the area where the medications are prepared.
- Take extra time with patients who have been prescribed anticoagulants and chemotherapeutic agents.
- To prevent nosocomial infections, hand washing should be routine before and after visiting each patient.
Accountability While it is true that individual providers should be held accountable for their decisions, there is a growing realization that the majority of errors are out of the clinician’s control. This being said, it remains difficult to change a culture of non-reporting. Questions to consider include:
- The potential for errors in healthcare is very high. Due to cost control measures, are individuals accountable, or are increased workload and staff fatigue the reason for errors?
- Why report? Failure to report errors may subject clinicians to disciplinary action and increased risk for legal liability. Beneficence and nonmaleficence are ethical concepts that are violated when an error is not reported.
- Practitioners often fear they will gain a reputation for committing mistakes and may not self-report. They know that mistakes and written warnings are often recorded in personnel files. Does the system need modification to decrease the penalty and encourage reporting?
Punishment may, in fact, reduce reporting errors because of the discipline and humiliation that is associated with repeated errors. Nevertheless, not addressing the problem increases the potential for more adverse events which places more patients at risk.
Rather than placing blame, administrators and review boards need to move toward eliminating the blame-shame-discipline structure and move toward a prevention and education structure. This culture incorporates both learning and improvement efforts that target system redesign and a reporting culture whereby all providers feel safe from retribution and, therefore, report issues about safety that help to constantly improve patient care and improve the safety of the system.
Definitions Patient safety has typically been outcome-dependent and the focus has been on preventing patients from experiencing adverse outcomes when receiving medical care. This may stem from Hippocrates, primum no nocere, or “First, do no harm.” While definitions in the literature are unclear, some general concepts can be garnered.
- Active errors are those taking place between a person and an aspect of a larger system at the point of contact.
- Active errors are made by people on the front line such as clinicians and nurses. For example, operating on the wrong eye or amputating the wrong leg are classic examples of an active error.
Adverse Event An adverse event is a type of injury that most frequently is due to an error in medical or surgical treatment rather than the underlying medical condition of the patient. Adverse events may be preventable when there is a failure to follow accepted practice at a system or individual level.
- Not all adverse outcomes are the result of an error; hence, only preventable adverse events are attributed to medical error.
- Adverse events can include unintended injury, prolonged hospitalization, or physical disability that results from medical or surgical patient management.
- Adverse events can also include complications resulting from prolonged hospitalization or by factors inherent in the healthcare system.
- These are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure.
- These are present but may go unnoticed for a long time with no ill effect.
- When a latent error occurs in combination with an active human error, some type of event manifests in the patient. The active human error triggers the hidden latent error, resulting in an adverse event.
- Latent errors are basically “accidents waiting to happen.” A classic example is a hospital with several types of chest drainage sets, all requiring different connections and setups, yet not all frontline clinicians and nurses are familiar with the intricacies of each setup, creating the scenario for potential error.
- The failure to complete the intended plan of action or implementing the wrong plan to achieve an aim.
- An unintended act or one that fails to achieve the intended outcome.
- Deviations from the process of care, which may or may not result in harm.
- When planning or executing a procedure, the act of omission or commission that contributes or may contribute to an unintended consequence.
Failure to meet the reasonably expected standard of care of an average, qualified healthcare worker looking after a patient in question within similar circumstances. For example, the healthcare worker may not check up on the pathology report which led to a missed cancer or the surgeon may have injured a nerve by mistaking it for an artery.
Negligent Adverse Events
- A subcategory of preventable, adverse events that satisfy the legal criteria used in determining negligence.
- The injury caused by substandard medical management.
- Any event that could have had an adverse patient consequence but did not.
- Potential adverse events that could have caused harm but did not, either by chance or because someone or something intervened.
- Near misses provide opportunities for developing preventive strategies and actions and should receive the same level of scrutiny as adverse events.
Never Event Never events are errors that should not ever have happened. A classic example of a never event is the development of pressure ulcers or wrong-site surgery. The National Quality Forum has identified the following as Serious Reportable Events:
- Care Management
- Patient Protective
Untoward events, complications, and mishaps that result from acceptable diagnostic or therapeutic measures that are deliberately instituted. For example, sending a hemodynamically unstable trauma patient for prolonged imaging studies instead of the operating room. The result could be a traumatic arrest and death.
Patient Safety The process of amelioration, avoidance, and prevention of adverse injuries or outcomes that arise as a result of the healthcare process. Potentially Compensable Event
- An error that could potentially lead to malpractice claims.
- An event due to medical management that resulted in disability, and, subsequently, a prolonged hospitalization.
Root Cause A deficiency or decision that, if corrected or avoided, will eliminate the undesirable consequence. Common root causes include:
- Changes in mental acumen including not seeking advice from peers, misapplying expertise, not formulating a plan, not considering the most obvious diagnosis, or conducting healthcare in an automatic fashion.
- Communication issues, having no insight into the hierarchy, having no solid leadership, not knowing whom to report the problem, failing to disclose the issues, or having a disjointed system with no problem-solving ability.
- Deficiencies in education, training, orientation, and experience.
- Inadequate methods of identifying patients, incomplete assessment on admission, failing to obtain consent, and failing to provide education to patients.
- Inadequate policies to guide healthcare workers.
- Lack of consistency in procedures.
- Inadequate staffing and/or poor supervision.
- Technical failures associated with medical equipment.
- No audits in the system.
- No one prepared to accept blame or change the system.
Sentinel Event The Joint Commission defines a “sentinel event” as “any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.The phrase ‘or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” (The Joint Commission, 2017).
- Depending on the study, medical errors account for over $4 billion per year.
- Medical errors cost approximately $20 billion a year.
- Medical errors in hospitals and clinics result in approximately 100,000 people dying each year.
- Medical errors typically include surgical, diagnostic, medication, devices and equipment, and systems failures, infections, falls, and healthcare technology.
- Missed diagnoses or injuries from medication are common in outpatient settings.
- Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care are related to missed or late diagnosis.
- Slightly more than half of the paid malpractice claims are related to outpatient care.
- To decrease overhead, hospitals often reduce nursing staff; staffing of RNs below target levels is associated with increased mortality.
What is the best way to prevent medical errors?
- If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done. Having surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery.
- If you have a choice, choose a hospital where many patients have had the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.
What is one approach used to prevent medical errors?
Plan-Do-Study-Act Cycle – Another system approach to eliminating medical errors is called Plan-Do-Study-Act (PDSA) approach, devised by the Institute for Healthcare Improvement. This strategy has been widely used by the Institute and many other healthcare organizations.
One of the unique features of this strategy is the acknowledgement that change is cyclical in nature and benefits from small and frequent PDSAs rather than big and slow ones, before changes are made system-wide (IHI, 2017). The PDSA cycle tests a change by “developing a plan to test the change (Plan), then carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act)” (IHI, 2017).
IHI Open School: Whiteboard: PDSA in Everyday Life (Part 1) https://www.youtube.com/watch?v=_-ceS9Ta820Published March 28, 2012
How can we prevent avoid and detect medication errors?
A new study has highlighted the ongoing problem of medication errors in the NHS. Dr Pallavi Bradshaw, senior medicolegal adviser at Medical Protection, says that clinicians are only human – and help is at hand – A new study commissioned by the Department of Health and Social Care (DHSC) has highlighted the impact of medication errors across the NHS in England.
While some of the figures make for stark reading – an estimated 700 annual deaths caused by such errors, at a cost of nearly £100 million – it is encouraging to see such open debate and action on the issue. Medication errors account for a considerable number of complaints, claims and patient safety incidents and the government’s desire to tackle the issue is welcomed.
At Medical Protection we have long provided advice, guidance and practical workshops to help members avoid such errors occurring. In our experience, common causes of medication errors are:
Wrong name Wrong drug Wrong dose Wrong frequency Wrong supply
When writing prescriptions, it is important to consider some fundamental points. Although they may seem obvious, in a busy clinical setting they are easily overlooked:
Be sure that the treatment is indicated. Check that the intended drug is not contraindicated and that the patient does not have a history of adverse reactions to it. Ensure that it will not interact with the patient’s other medication and warn the patient about any potential interactions with over-the-counter medicines. Write legibly, taking special care if the drug name could easily be confused with another – use capital letters and give the generic rather than trade name. If you’re not sure which of two similar sounding drugs you should be prescribing, check with a senior colleague and confirm the correct spelling in the BNF. Write clear and unambiguous instructions for dosage, frequency and route of administration, avoiding abbreviations and leading decimal points (put a zero in front of it, eg, 0.2mg). Note the prescription and any other relevant information (eg, warnings given to the patient) in the medical record. Ensure that the patient is aware of what is being prescribed, and why. Use patient information leaflets to augment your verbal instructions, and be particularly careful to warn patients about possible side-effects, adverse drug interactions (including herbal medicines), or potentially dangerous activities, such as driving while taking drugs that induce drowsiness.
How can nurses prevent medical errors?
Preventing missteps – Proficiency in drug calculations is essential for safe medication administration. Having sound basic mathematical skills and performing accurate drug calculations can significantly minimize medication errors. Nurse educators play an important role by having an education plan in place to ensure nurses maintain their proficiency in medication calculation.
- Simulated practice in medication administration can benefit nurses without the risk of harm to patients.
- Nurses must improve their pharmacologic knowledge and keep up-to-date about new drugs.5 Ongoing medication competency must be maintained.
- Pharmacologic continuing education updates nurses about the safe use of new drugs, including appropriate indications and dosages, proper administration, drug actions, contraindications to use, drug-drug interactions, potential adverse drug reactions, patient monitoring, patient teaching, and documentation.
Interventions to decrease distractions can enhance patient safety. Some healthcare facilities have implemented the sterile cockpit rule, which means eliminating distractions during medication preparation to avoid medication errors. This strategy was developed by the airline industry in the 1980s to preserve safety in the cockpit area by preventing nonessential activities or conversations during the critical phase of flight.
- In a study by Fore et al., the rate of medication errors dropped by 42.78% when this rule was in place.12 Because nurses tend to be in constant communication with their patients and the healthcare team, the sterile cockpit rule may be challenging to implement.
- A “do not disturb” or “quiet zone” sign in the medication preparation area can help minimize distractions.
To safeguard against medication errors, nurses must implement the proper procedures for medication administration, including at least these five rights: right patient, drug, dose, route, and time. In addition, they must complete accurate documentation once the patient receives the medication.11,13 Failure to record the medication administered increases the risk that the patient will receive another dose.
- Nurses should be cautioned not to document the dose before the medication is given because, for one reason or another, the patient may not receive the medication at all or might receive it at a different time than documented.
- Patients need to be well informed of medications’ therapeutic effects, potential adverse reactions, and desired outcomes.
Evaluating the effect of certain medications is crucial to ensure the patient has responded to the medication; for example, high blood glucose levels may be treated with sliding scale insulin dosages. The patient’s blood glucose levels must be closely monitored to ensure they’re within the desired therapeutic range, and the patient must be closely monitored for and taught to report adverse reactions, such as signs and symptoms of hypoglycemia.
- When administering an analgesic, the nurse must first assess the patient’s pain level, administer the analgesic drug, and then monitor for adverse reactions and evaluate and document the therapeutic response.
- If the desired effect isn’t achieved, the patient may have received an inadequate dose or may require a different analgesic for pain control.
Many medications can be administered via different routes, such as oral or I.V., increasing the possibility of confusion. Some forms of medications, such as enteric-coated medications intended to prevent stomach irritation, shouldn’t be crushed. Nurses should frequently double-check to ensure they’re administering medications via the correct route and in the prescribed form.
- Providers may prescribe specific I.V.
- Dosing regimens based on their own preference and previous experience, institutional standards, and smart pump setup.
- For example, dopamine infusion titrations may be prescribed using microgram/kilogram/minute dosages or microgram/minute dosages to maintain the mean arterial pressure above 65 mm Hg.
Using multiple dosing methods for the same drug can be confusing, increasing the risk of errors.14 Standardizing the dosing method for I.V. medications such as epinephrine, midazolam, and nitroglycerine infusions in the ICU could minimize dosing errors.15 Referring to a list of high-alert drugs can help safeguard nurses from making medication errors.16 Understanding the placement of decimals is crucial; for example, 0.20 mg is 10 times greater than 0.02 mg.
- Nurses need to have a clear idea of decimal placement and values to avoid calculation errors.7 Technology such as smart pumps and bar code-assisted medication administration (BCMA) can help to decrease drug-dosing errors when used appropriately.
- Nurses using BCMA scan the patient wristband and medication codes before administering medications.
In one study, BCMA decreased wrong dosage errors by 90.4%, medication administration errors by 80.7%, and medications lacking prescriptions by 72.4%.17 I.V. smart pumps have error-prevention software, drug libraries, and dosing limits that give an alert when the dosing is out of range.15,18 Manrique-Rodríguez et al.
- Studied the benefits of using I.V.
- Smart pumps in pediatric ICU patients.18 A total of 624,252 infusions were initiated, and 486,875 medications were programmed through the smart pump drug library.
- User safety software compliance was 78%.
- Using the smart pump device resulted in 92 cases of programming errors being intercepted; 84% of these medications were for pain, sedation, cardiac conditions, and infections.
Using smart pumps enhanced patient safety. Reporting medication errors helps identify failures in medication processes and may help to prevent further incidents. When medication errors are reported, risk managers use the information to better understand the root causes and develop policies and procedures to prevent future patient harm.
What are the three common causes of medication errors?
What are Medication Errors? – The National Coordinating Council for Medication Error and Prevention (NCCMERP) has approved the following as its working definition of medication error: “. 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 and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”. This concept paper focuses on the types of medication errors that take place in the ambulatory setting-that is, among patients who self-administer their medications, rather than those patients receiving medications in a clinic or hospital setting.
The types of errors that occur in this environment differ from those that occur in institutional settings; this paper will not address the issues and efforts undertaken by pharmacy colleagues in those practice settings. How Do Medication Errors Occur? The provision of drug therapy by a medical provider to a patient is a complex process.
- Errors can occur at any step along the way, from prescribing to the ultimate provision of the drug to the patient.
- Common causes of medication error include incorrect diagnosis, prescribing errors, dose miscalculations, poor drug distribution practices, drug and drug device related problems, incorrect drug administration, failed communication and lack of patient education.4 One of the largest causes of therapeutic medication misadventures is incorrectly prescribed medication.
The number of patient deaths resulting from drug errors has increased from 198,000 in 1995 to 218,000 in 2000. The cost of these misadventures to the US economy is more than $177 billion per year.5 Preventable errors occur because systems for safely prescribing and ordering medication are not appropriately used.
A widely recognized cause of error is illegible handwritten prescriptions. Errors may result from insufficient or missing information about co-prescribed medications, past dose-response relationships, laboratory values and allergic sensitivities. Errors in prescribing can occur when an incorrect drug or dose is selected, or when a regimen is too complex. When prescriptions are transmitted orally, sound-alike names may cause error. Similarly, drugs with similar-looking names can be incorrectly dispensed when prescriptions are handwritten. Errors may occur because a prescription is never transmitted to a pharmacy, or a prescription is never filled by the patient. Physician sampling of medications can contribute to medication errors due to the lack of both adequate documentation and drug utilization review.
The term dispensing error refers to medication errors linked to the pharmacy or to whatever health care professional dispenses the medication. These include errors of commission (e.g. dispensing the wrong drug, wrong dose or an incorrect entry into the computer system) and those of omission (e.g.
- Failure to counsel the patient, screen for interactions or ambiguous language on a label).
- Errors may be potential – detected and corrected prior to the administration of the medication to the patient.6 The three most common dispensing errors are: dispensing an incorrect medication, dosage strength or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications.
Errors caused by drug administration can be made by the health care provider or by the patient themselves. Much of the problem in drug administration is communication. Patients are often unaware that errors can happen and often do not take an active role in understanding what is being communicated to them.
Errors most often occur when communication is unclear regarding: drug name, drug appearance, why the patient is taking the drug, how much and how often to take it, when is the best time to take it, how long to take it, what common side effects could occur, what to do about a missed dose, common interactions with other drugs or foods, and whether this new drug replaces or augments other therapy.
Over-the-counter medications can lead to medication errors because labels may not be sufficiently read or understood, and health care providers are often unaware when patients are taking over-the-counter medications. The types of errors described above are primarily errors of commission.
- There are also errors of omission, such as the failure to administer a drug that was prescribed or not administering a drug in a timely manner.
- Although they are much more difficult to identify through systematic reporting tools, errors of omission must also be addressed through process improvement efforts in order to truly improve patient safety in a comprehensive manner.
Attitudes About Medication Errors Medical professionals, including physicians, nurses and pharmacists, do not deliberately commit medication errors. They are trained to deliver “error free” health care. However, when errors are discovered, there is an attitude of placing “blame” on the professional(s) involved in the incident.
- Formal punishment by the individual’s profession is sometimes administered, resulting in fines, license suspension or even license revocation.
- More importantly, the individual may be punished by the lost respect of his or her fellow health care professionals, which may be even more devastating than a professional reprimand.7 Where medication errors are concerned, the question of who was involved is of less importance than what, how and why the system went wrong.8 An investigation of medication errors should begin with an analysis of the drug use and delivery channels within a health care system, rather than result in punitive action directly targeted to the health care provider involved with the error.
Although there is no acceptable level of error within the medical care system, the goal of health care organizations should be to evaluate errors when they occur and to make changes in the drug delivery process to prevent them from reoccurring in the future or elsewhere.
AMCP encourages all medical professionals to take responsibility in efforts to identify, monitor, evaluate and prevent medication errors, and believes that managed care organizations should establish a nonthreatening, non-punitive and confidential environment that encourages health professionals to report medication errors in a timely manner.9 Reporting Medication Errors Health care professionals and consumers have the opportunity to report the occurrence of medication errors to a variety of organizations.
Examples include the Institute of Safe Medication Practices (ISMP) and the Food and Drug Administration (FDA). These organizations collectively review error submissions. Case reports are published to educate health care professionals regarding errors and near errors.
In some cases, the FDA may work with drug manufacturers and others to inform them about concerns with pharmaceutical labeling, packaging and nomenclature to make appropriate changes to reduce the risk of medication errors.10 AMCP has voiced support for a medication error reporting system that encourages participation and provides confidentiality and protection of the information reported and the person(s) reporting.
To be successful a medication error reporting system must have protections for those reporting. Often, pharmacists view mandatory reporting laws and regulations as punitive, especially if public disclosure is included. Compliance with such programs is likely to be less than optimal since the results of reporting could include lawsuits, regulatory enforcement actions, forfeiture of pharmacy license, and loss of professional reputation with accompanying loss of business.11 Regulatory and advocacy activity provides for improving monitoring of medication errors.
The FDA MedWatch reporting system provides a comprehensive sentry position for many medication errors to be reported. Although designed primarily for reporting adverse events from medication use, FDA’s MedWatch is an appropriate venue to discover medication errors, such as prescribing misadventures and look-alike, sound-alike errors leading to adverse reactions.
Many state boards of pharmacy have begun medication error reporting initiatives to detect trends in ambulatory dispensing errors. At this point in time, most are limited to mandatory internal reporting systems within a setting, as is the case in California, where errors must be logged and open for board inspection during routine visits and complaint investigation.
Many physician boards and associations participate in prescribing error investigations, driven primarily by peer review and consumer complaint resolution. Managed Care Pharmacy and Medication Errors The vast majority of prescriptions filled in the United States are paid for and administered by managed care organizations.
These organizations can influence health care providers and their professional societies as well as consumers to encourage medication error reporting and prevention. Quality improvement programs within managed care organizations include mechanisms for reporting medication errors, examining and evaluating causes of errors, analyzing aggregate data to determine trends and making necessary changes within their health care delivery system to prevent errors from occurring.
What are the 5 rights to prevent medication errors?
The Five Rights: A Destination Without a Map As we have discussed in previous columns, errors in drug administration pose a great risk to patients. Most health care professionals, especially nurses, know the “five rights” of medication use: the right patient, the right drug, the right time, the right dose, and the right route—all of which are generally regarded as a standard for safe medication practices.
Yet many errors, including lethal mistakes, have occurred even when health care professionals were confident that they had verified these “rights.” Why does this happen? First, although these criteria are the goals of safe medication practice, they offer little guidance to health care practitioners on the appropriate way to ensure drug safety.
For instance, how does a pharmacist identify the right patient when the patient’s name and room number on an order copy are blurred and the physician’s signature is illegible? Whom should the pharmacist call for follow-up? How does a home-care nurse in an assisted-living facility identify the right patient if name bracelets are not used? Can the nurse depend on verbally questioning the patient? Unfortunately, relying on accurate information from patients has led to errors, for instance, when patients misunderstood a name or when they were confused.
Without adequate systems in place to help practitioners achieve the goals of the five rights, errors are likely. The five rights, as stated, focus on the performance of individuals and do not reflect the fact that drug safety is a culmination of efforts of professionals from several disciplines; the responsibility for accurate drug administration lies with multiple individuals and reliable systems.
Some of the factors contributing to a medical team’s failure to accurately verify the five rights, despite their best efforts, include:
poor lighting. inadequate staffing patterns. poorly designed medical devices. handwritten orders. trailing zeroes (e.g., 2.0 vs.2) or using a decimal point without a leading zero (e.g.,,2 instead of 0.2). Misinterpretation of such an order can result in a 10-fold dosing error. ambiguous drug labels. lack of an effective independent double-check system for high-alert drugs.
Nurses, for example, cannot verify the identity of the patient if they have no way of knowing whether patients are actually who they say they are or whether the name on a patient’s armband is accurate. They can only verify two unique identifiers assigned to the patient upon admission to the facility—a process that the organization deems to be sufficient to confirm that the identity of the patient—before they administer medications.
reading the label requesting an independent double-check if required questioning orders for drugs and doses that are illegible or that appear unsafe using bar-code technology if it is functional
Organizations consider these procedural rules to be sufficient to verify the right drug and the right dose. Thus, the duty of the health care practitioner is not so much to achieve the five rights but to follow the procedures designed by the organization to produce these outcomes.
- If the procedural rules cannot be followed because of problems within the system, health care practitioners also have a duty to report the matter so that it can be fixed.
- Although some might think that this distinction is minor, it is helpful to consider the following.
- If we hold individuals accountable for achieving the five rights, we should then give them the authority to design their own systems for achieving these outcomes.
After all, how can we hold individuals accountable for situations and events that are not under their control? However, because organizations typically decide on the processes that are necessary for achieving the five rights, staff members who follow these procedures should not be held individually accountable for undesirable outcomes.
Improvements must be made in the systems themselves, not in the individual’s practice or behavior. The five rights are not a behavioral model for achieving medication safety; they are goals for which organizations must accept responsibility and design fail-safe ways so that the goals can be achieved.
Of course, the five rights are not the final word in medication safety. Unfortunately, managers often simply admonish health care practitioners who make an error for not following the five rights without recognizing or addressing the human factors and causes of the error originating within the system.
Likewise, regulatory agencies often penalize health care professionals if they cannot verify the five rights; such actions perpetuate the belief that individuals should be blamed. The five rights should remain as medication-use goals, but we must help practitioners achieve these goals by establishing strong support systems that encourage safe practices.
The reports described in this column were received through the ISMP Medication Errors Reporting Program (MERP). Errors, close calls, or hazardous conditions may be reported on the ISMP Web site () or communicated directly to ISMP by calling 1-800-FAIL-SAFE or via e-mail at,
Can we avoid medication errors?
Avoiding Medication Errors US Pharm.2020;45(6):10-11. Medical errors and drug-administration mistakes pose significant patient risks. These errors contribute to avoidable patient deaths in the hospital environment. To maintain patient safety and avoid medication errors, it is important that pharmacists, nurses, and other healthcare professionals adhere to the standard for safe medication practices, known as the “five rights” of medication use: the right patient, drug, dose, time, and route.1 Hospital medical mistakes cause as many as 98,000 deaths annually.
- That exceeds the number of deaths from breast cancer, AIDS, or motor vehicle accidents.
- Medication errors cause more deaths each year than workplace injuries.
- The financial cost of these errors compounds the urgent need to address this underappreciated and widespread problem.2 Nurses acquiring medication from a medication dispensing machine should evaluate the medication administration record (MAR) for all five medication-use rights.
Adherence to the five rights is not a guarantee against medical errors, however; minor or major mistakes can still occur.1,2 Over the past several years, new technologies to eliminate medication errors have been introduced to the healthcare market, including electronic orders and charting, bar coding that matches patients with medical records, and computerized medication distribution.
What is the most common type of medical error?
1. Diagnostic Errors and Mistakes – Misdiagnosis, failure to diagnose, and delayed diagnosis are some of the most common types of medical errors. For example, doctors may fail to order diagnostic tests or interpret the results of a diagnostic test correctly.
Who is first one to prevent medication error?
Apr 10, 2020 Drug Topics Journal Drug Topics April 2020 Pharmacists are positioned to play a key role in preventing or catching errors that can occur at the various stages of the drug-use process: prescribing, dispensing, and administration. It’s been 20 years since the Institute of Medicine released its landmark To Err is Human report, but medication errors remain a serious problem in our health care system. Pharmacists are positioned to play a key role in preventing or catching errors that can occur at the various stages of the drug-use process: prescribing, dispensing, and administration.
Here are some strategies that can help.1. MINIMIZE CLUTTER The pharmacy environment is often fast-paced and intense, with high prescription volume, insufficient staffing, and demanding patients. Keeping pharmacy counters clear and clutter free can be challenging, but it is an important part of reducing risk for dispensing errors, said Matthew Grissinger, RPh, director of error reporting programs at the Institute for Safe Medication Practices (ISMP) in Horsham, Pennsylvania.
He advises pharmacies to use a basket system to keep different patients’ prescriptions and drugs separate, as well as to clear away the bottles from prescriptions that have been completed. Ideally, he said, pharmacists should take phone calls in a quiet, distraction-free area.2.
VERIFY ORDERS For prescriptions called in by phone, it’s important to write down and then repeat the order to verify that it was heard correctly; ISMP recommends spelling drug names during read back.1 E-prescribing comes with its own pitfalls, according to Dixie Leikach, RPh, vice president of Catonsville and Paradise Professional Pharmacies in Catonsville, Maryland.
Her pharmacy often deals with problems caused by improper use of the technology. For example, sometimes prescribers can’t find the correct drug strength or dosage form on the e-prescribing dropdown menu, so they select a similar drug from the list and then write the intended product in notes in other areas of the prescription, which can be missed during order entry.
- We’ve learned over time that we have to read all the information and clarify if something really doesn’t make sense,” Leikach said.3.
- USE BARCODES Scanning barcodes plays an important role in checking that the correct drug, dosage form, and strength has been selected, Grissinger said, ensuring that the most common dispensing errors are avoided.
But he cautions that in the retail environ- ment, this will only work if orders are entered in the system before selecting the drug bottle; if pharmacists pull the wrong drug off the shelf and enter its NDC number, barcoding will not catch that error because the incorrect barcode will appear on the prescription label.
At Boulder Community Health (BCH) in Boulder, Colorado, where Christopher Zielenski, PharmD, is pharmacy clinical coordinator, the use of barcoding throughout the system, from dispensing through administration, has resulted in a huge reduction in errors. Since they began requiring barcode scanning for medications being placed in automatic dispensing cabinets, the rate of mistakes in filling medications has been reduced to nearly zero, he reported.4.
BE AWARE OF LOOK-ALIKE SOUND-ALIKE (LASA) DRUGS ISMP maintains a long list of drugs with similar names that may be confused, which it recommends printing in bolded tall man (uppercase) letters (eg buPROPion/busPIRone).2 It is imperative for pharmacists to stay informed about what those drugs are, experts said.
Grissinger advised that every pharmacy choose 5 common LASA pairs and develop strategies to avoid errors with them, such as separating them. If drugs are separated, he cautioned, pharmacists and techs need to know where they are located. Leikach said that LASA lists grow as more drugs become available in generic formulations.
She gave risperidone and ropinirole as an example. “When those were brand names they weren’t a problem, but once they both went generic and they’re both available in the same strength. and they’re sitting next to each other on the shelf, all of a sudden you’ve got a huge potential for pretty severe med errors and adverse drug effects.” 5.
HAVE A SECOND PAIR OF EYES CHECK PRESCRIPTIONS One way to prevent human error is by involving a second human-a pharmacist or technician (as permitted by state law)-in the dispensing process. “If I’m the one taking the prescription and entering it, then I’m not pulling the drug and counting it, because I know I have to final check it,” Leikach said.
“Someone else, a tech or another pharmacist, will look at it. We check each other.” When she worked in environments where there was no one else there to check, she would walk away from prescriptions once she’d reached a certain point in the dispensing process, so that she could come back with “a fresh set of eyes.” Grissinger cautioned that final checks should always include verification of the original order entry, whether by keeping the paper prescription with the label and medicine bottle until completion or by pulling up the scanned prescription on the computer screen.6.
- DESIGN EFFECTIVE WARNING SYSTEMS Various alert strategies can be helpful, but human nature is to overlook the familiar.
- That’s why Leikach moves around shelf talkers alerting staff about LASA drugs so they continue to catch the attention of staff members.
- She has also requested that the pharmacy software system change some alerts to hard stops, so that the pharmacist or technician is required stop, read the alert, and type a response-thus ensuring that they pay attention.7.
INVOLVE THE PATIENT Patients are their own last line of defense when it comes to medication errors, and investing a minute or 2 in speaking to them can reap huge dividends in catching medication errors. Grissinger advises asking the patient when they pick up the prescription: “Open the bag; is this what you were expecting? Look at the label, look at the name of the drug, look inside the bottle if it’s a refill to make sure it’s what you got last time.” Basic counseling can help ensure that patients understand what their prescription is for and how to take it properly; it sometimes helps catch errors as well.
- Leikach recalled situations where she could tell that her explanation did not make sense to the patients.
- They said, ‘That’s not why I went to the doctor, that’s not what he told me!'” This enabled her to catch medication errors made by the prescriber or the dispensing pharmacist, she said.
- Speaking to patients is also valuable in obtaining an accurate medication reconciliation, Zielenski noted, which is why BCH has instituted training in active listening for staff involved in medication reconciliation.8.
TRUST YOUR GUT “Pharmacists need to recognize their role to the patient,” Leikach said. “When you receive a prescription-especially if you get to know your patients-then if something doesn’t make sense don’t just let it go.” Question the patient and call prescribers to verify, she advised, and if necessary, dig deeper to obtain clarification on why something was prescribed as it was and whether it was a mistake.
- After enough occasions of being thanked by prescribers for catching their errors, Leikach realized that “you really do need to push when you feel that something isn’t right,” she said.9.
- BE PROACTIVE “Let’s not keep waiting for things to go wrong and fix them,” Grissinger said.
- Experienced pharmacists can sense when things are not going right and should address those concerns, he said.
“Otherwise something’s going to go wrong and the pharmacist is going to get blamed for that when we saw it coming a mile away.” ISMP has free self-assessment tools that pharmacists in different practice settings can use to evaluate how well they are maintaining patient safety.
Its Medication Safety Self Assessment® for Community/Ambulatory. Pharmacy includes over 200 items in 10 elements important for safe medication use. Sometimes, Zielenski said, simple changes can have a big impact. For example, BCH started stocking batteries on the floors after pharmacists realized that barcode medication administration rates were dropping due to scanner batteries running out.
Similarly, BCH includes dosing and administration instructions with emergency kits. “Those types of tools can be implemented anywhere,” he noted. “Frontline staff can develop them; it doesn’t have to come from a manager.” 10. TRACK MEDICATION ERRORS “I believe in reporting safety events-which are classified as near-misses and errors-even if they are your own, to allow a big picture to develop so we can identify trends at the system level and then address those issues and encourage peer-to-peer feedback,” said Zielenski.
He recently published an article describing how BCH developed several interdisciplinary committees that used medication safety events reported through its voluntary electronic safety event reporting system to perform continuous quality improvement throughout the hospital.3 Over the course of 3 years, there was a significant drop in rates of medication errors and concomitant increase in the rate of near misses, while reporting rates remained the same.
Open discussion of medication errors is most helpful when an institution has a just culture perspective, Zielenski added. “As soon as it becomes part of a normal conversation, I think that’s where you really start to gain traction on reducing medication errors,” he said.
What is the principle of error prevention?
What can we learn from this? – The key takeaway here is that users will always make mistakes. Therefore, a good UX strategy would be to:
- Prevent unconscious errors by offering suggestions as users are often distracted from the task at hand.
- Use design patterns that communicate how they work to users, encourage users to double-check their work (especially before deleting), and warn before mistakes are made. These simple guidelines can help enable lower rates of user errors, and ultimately improve usability.
When you design conscientiously like this, you can stay one step ahead of your users and prove your brand’s empathy with them and the realities they face every day—a world of applying for jobs, checking for updates while worrying about people and things they care about, and all the rest of what being a human being involves.
Why is it important to prevent medication errors?
4. Discussion – The goal of the drug therapy is the achievement of the best therapeutic outcomes and the improvement of the patient’s quality of life. Unfortunately, there are hazards associated with the therapeutic use of drugs, including adverse drug reactions and medication errors ( Helper & Stand, 1990 ).
- Medication errors have significant implications on patient safety.
- These errors occur at all stages in medication use: ordering, prescription, dispensing, and administration.
- Error detection discloses those errors and thus, encourages a safe culture ( Montesi & Lechi, 2009 ).
- In an earlier study at two teaching hospitals, 616 MEs were found out of 10778 observed medication doses at a rate of (5.7%) ( Kaushel et al., 2001 ).
Among 16,938 medication orders in a study on pediatric inpatients at a large academic community hospital, there were 865 medication errors noted, a rate of 5.2 per 100 orders ( Wang et al., 2007 ). In the current study, medication errors constitute (6.7%) of all the administrations: 1467 errors out of 21843observations.
- In an earlier Egyptian study, 1107 of the medication orders (78.1%) had at least one prescription error ( Alagha, Badary, Ibrahim, & Sabry, 2011 ).
- In a descriptive analysis of medication errors reported to the Egyptian national online reporting system, out of the 12000 valid reports that were analyzed, prescription errors were the most common type of MEs (54%), followed by monitoring (25%) and administration errors (16%) ( Shehata, Sabry, & Elmelegy, 2015 ).
In the current study: The most common stage for medication errors was during the ordering and prescription stage (38.1%), followed by the administration stage, (20.9%). Errors during monitoring, preparation and dispensing were: (18.3%), (12.3%) and (10.4%), respectively.
Published research indicates that not all MEs cause harm ( WHO, 2014 ). Several approaches that are used to assess errors preventability depend mainly on the researcher’s own judgement. ( Ferner & Anorson, 2006 ) In the Egyptian study ( Shehata et al., 2015 ), (25%) and (11%) of errors were potential and prevented errors versus (7.7%) and (47.4%) in this study, respectively.
About 45% of errors in Dar El Shefaa, during the baseline measurement, affected patients: 43.5% were harmless and 1.4% was harmful versus 51% harmless and 13% harmful errors reported to the Egyptian national online reporting system, from June to December 2014.
- There are multiple tools for error detection given the available resources.
- Medication errors are detected by voluntary reporting, direct observation, and chart review.
- Organizations need to establish systems for prevention of medication errors through analyzing the cause of errors to identify opportunities for quality improvement and system changes ( Morimoto, Seger, Hsieh, & Bates, 2004 ).
Each tool has its specific advantages: and its limitations: e.g. direct observation is used for detection of dispensing and administrative errors more than prescription and monitoring errors. Chart review is a reliable method for detection of prescription errors more than detection of administrative errors ( Morimoto et al., 2004 ; WHO, 2014 ).
For that, in the current study errors during drug prescription, dispensing, preparation and administration phases, decreased from: (38.1%) to (35.5%); (10.4%) to (7.0%), (12.3%) to (11.7%) and from (20.9%) to (19.9%) respectively. On the other hand, monitoring errors increased significantly from (18.3%) to (25.9%).
In a study to identify and prioritize effective strategies to reduce medication errors: 81% of the physicians suggested to activate the role of a ward based clinical pharmacists ( Fortescue et al., 2003 ). Clinical pharmacists are trained in therapeutics and provide comprehensive drug management to patients and providers.
Accordingly, clinical pharmacists are capable of managing medication therapy in a patient care setting, in collaboration with other health care professional ( Peter, Kaboli, Angel, Hoth, & McClimer, 2006 ) The pharmacist’s role is to ensure that all patients reach the optimum benefit from medications.
Through a system-oriented approach, the pharmacist should lead coordinated, multidisciplinary efforts to prevent and detect drug-related problems that could cause harm ( Helper et al., 1990 ). The pharmacist should participate in appropriate organizational committees and work with physicians, nurses, and other staff to ensure that medication processes are safe ( Lesar et al., 1990 ).
- Hence, in the current study, the pharmacist, in each ward, monitored all stages of medication, from the drug’s ordering to the administration of the drug.
- They reviewed patient files and prepared errors’ report.
- A multidisciplinary committee reviewed all submitted reports.
- Accordingly, the training program was developed and conducted during the intervention phase.
The intervention succeeded to decrease the error rate by 46.3%. The medication errors decreased progressively during the study period (3.6%) in the post test period versus (6.7%) of all observed doses during the pretest phase. In a study to examine the impact of clinical pharmacist intervention in preventing harm from medication errors in 2 children’s hospitals during 6-month period, the error rates before and after clinical pharmacist intervention were 4.9 and 4.5 errors per 1000 medication orders, respectively ( Folli, Poole, Benitz, & Russo, 1987 ).
Utilizing a continuous quality improvement approach, a 2 year prospective cohort study used an adverse incident reporting scheme and a multidisciplinary committee to analyze medication error reports. Consequently, changes in policy and practice were implemented to reduce the errors. During the second year, the incidence of all reported errors fell ( Wilson et al., 1998 ).
The incidence of medication errors decreased significantly, from 49% to 31% after an educational intervention in medication preparation and administration in a tertiary Neonatal Intensive Care Unit ( Chedoe, Molendijk, Hospes, Van den Heuvel, & Taxis, 2012 ).
In a study of medication errors among neonatal and pediatric inpatients, including the impact of a series of interventions to reduce errors: before the interventions, the medication error rate was 11.4% compared with 7.3% after the interventions ( Otero, Leyton, Mariami & Gernadas, et al., 2008 ). The introduction of tutorial prescribing routine in a pediatric unit at a district general hospital in the United Kingdom decreased prescription errors by 46% ( Davey, Britland, & Naylor, 2008 ).
In the current study, ordering and prescription errors was the most common cause of MEs (38.1%) during the baseline measurement and decreased to (35.5%) following the intervention. Physicians were responsible for 72% of errors in a study of medication errors in pediatric practice ( Wilson et al., 1998 ).
Physicians of Dar El Shefaa were responsible for 57% of MEs that decreased to 52.8% of errors after staff education. On the other hand the percent of errors caused by nurses and pharmacists increased insignificantly during the same period. The study highlights the importance of error reports as sources of information for the generation of preventive strategies aimed toward medication error reduction.
Reports were analyzed quantitatively and qualitatively for identification and prioritization of error medication stages, their effect on the patient and their root causes. Hence corrective actions targeted priority areas and root causes to prevent recurrence.
- The study emphasized both the need and effectiveness of quality-improvement programs that focus on educating the staff about the medication errors and the importance of reporting.
- Monitoring by clinical pharmacists proved to be an effective method for error detection.
- The strategies explored in this study can assist any organization in decreasing rates of medication errors and in patient safety enhancement efforts.
Due to the high risk of MEs among pediatrics and intensive care units, many earlier studies described MEs among those populations. In this study, the risk of MEs among adults in the inpatient wards was investigated extensively. The study had some limitations: The differences of definitions and of error detection methods limit the comparison among different studies ( Vasin et al., 2014 ).
Organizations involved in reporting MEs use different terms and definitions. For an effective collaboration, there is a need to a common” language” ( Yu, Nation, & Dooley, 2005 ; WHO, 2014 ). The intervention was conducted over a limited duration (two monthes) which may have affected the findings. In addition, using the direct observation method for determining MEs was found to cause sometimes behavioral changes in the observed as the health care providers were aware of the study; the Hawthorne effect could have affected both the occurrence and detection of errors ( Dean & Barber, 2001 ).
It is also possible for the observer to fail to record certain MEs. The incidence of errors could have been reduced as the study progressed because corrective actions were taken as soon as serious practice problems were identified.
What strategies can nurses use to identify errors?
Abstract – Background: Medical errors are common in intensive care units. Nurses are uniquely positioned to identify, interrupt, and correct medical errors and to minimize preventable adverse outcomes. Nurses are increasingly recognized as playing a role in reducing medical errors, but only recently have their error-recovery strategies been described.
- Objectives: To describe error-recovery strategies used by critical care nurses.
- Methods: Data were collected by audio taping focus groups with 20 nurses from 5 critical care units at 2 urban university medical centers and 2 community hospitals on the East and West coasts of the United States.
- Transcript content was analyzed as recommended by Krueger and Casey.
Results: Analysis of focus group data revealed that nurses in critical care settings use 17 strategies to identify, interrupt, and correct errors. Nurses used 8 strategies to identify errors: knowing the patient, knowing the “players,” knowing the plan of care, surveillance, knowing policy/procedure, double-checking, using systematic processes, and questioning.
Nurses used 3 strategies to interrupt errors: offering assistance, clarifying, and verbally interrupting. Nurses used 6 strategies to correct errors: persevering, being physically present, reviewing or confirming the plan of care, offering options, referencing standards or experts, and involving another nurse or physician.
Conclusions: These results reflect the pivotal role that critical care nurses play in the recovery of medical errors and ensuring patient safety. Several error-recovery strategies identified in this study were also reported by emergency nurses, providing further empirical support for nurses’ role in the recovery of medical errors as proposed in the Eindhoven model.
What are 6 medication errors?Category Description Example A No error, capacity to cause error NA B Error that did not reach the patient NA C Error that reached patient but unlikely to cause harm (omissions considered to reach patient) Multivitamin was not ordered on admission D Error that reached the patient and could have necessitated monitoring and/or intervention to preclude harm Regular release metoprolol was ordered for patient instead of extended-release E Error that could have caused temporary harm Blood pressure medication was inadvertently omitted from the orders F Error that could have caused temporary harm requiring initial or prolonged hospitalization Anticoagulant, such as warfarin, was ordered daily when the patient takes it every other day G Error that could have resulted in permanent harm Immunosuppressant medication was unintentionally ordered at one-fourth the dose H Error that could have necessitated intervention to sustain life Anticonvulsant therapy was inadvertently omitted I Error that could have resulted in death Beta-blocker was not reordered post-operatively
What are practical ways to prevent errors with high alert medications?
Standardize the ordering, storage, preparation, and administration of medications. Limit access to high-alert medications, allow use of auxiliary labels, automated alerts, and other redundancies.
What are the 5 steps to complete medication reconciliation?
Background – According to the Institute of Medicine’s Preventing Medication Errors report, 1 the average hospitalized patient is subject to at least one medication error per day. This confirms previous research findings that medication errors represent the most common patient safety error.2 More than 40 percent of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients.3 Of these errors, about 20 percent are believed to result in harm.3, 4 Many of these errors would be averted if medication reconciliation processes were in place.
- Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders.
- According to the Joint Commission 5 (p.1), Medication reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking.
This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care.
This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.
Recognizing vulnerabilities for medication errors, numerous efforts are underway to encourage all health care providers and organizations to perform a medication reconciliation process at various patient care transitions. The intent is to avoid errors of omission, duplication, incorrect doses or timing, and adverse drug-drug or drug-disease interactions.