Reducing Medication Errors
Information for Healthcare Professionals

With the ever-increasing number of available prescription medications, opportunities for errors related to drug names, packaging, indications and adverse events are also increasing. Healthcare professionals must play a key role in preventing errors from occurring and in helping protect patients from harm when errors do occur.

This Web site, intended for professional use, suggests measures that healthcare professionals can take to enhance medication safety and provides links to additional professional resources.

Defining medication error
The National Coordinating Council for Medication Error and Prevention (NCCMERP), a national coalition of 20 organizations focused on prevention of medication errors, has approved this 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 healthcare professional, patient, or patient. Such events may be 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.”

Medication use is a complex process that includes a series of steps—medication prescribing, order processing, dispensing, administration and effects monitoring—any one of which could lead to medication error.

Several national organizations whose missions are focused on enhancing the safe use of prescription medicines have developed practical guidelines and tips for healthcare professionals. The following represents some of their key recommendations.

Tips for healthcare professionals to reduce medication errors

• Miscommunication between physicians, pharmacists and nurses is a common cause of medication errors. To minimize medication errors caused by miscommunication, it is important to verify drug information and eliminate communication barriers.
• Prescribers should avoid using abbreviations, including those for drug names because they can be misunderstood. Some examples of risky abbreviations include:
• µg (microgram)—can be mistaken for “mg” when handwritten and should be written as mcg
• q.d. or QD (every day)—can be mistaken as q.i.d., especially if the period after the “q” or the tail of the “q” is misread as an “i”; “daily” or “every day” preferred
• IU (international unit)—can be misread as IV; “units” preferred
• No zero before decimal point in dosage, for example, .5 mg (for 0.5 mg)—can be misread as 5 mg.
• Obtaining the patient’s pertinent demographic and clinical information will help practitioners select the appropriate medications, doses and routes of administration.
• Having complete patient information at the time of prescribing will result in a significant decrease in preventable adverse drug events (ADEs).
• Write prescriptions legibly and clearly, printing in block letters rather than writing in cursive. More than 15 percent of the prescription errors in the USP Medication Error Reporting database resulted from poor handwriting and misinterpretation of medication orders.
• Educate patients by using brochures when speaking to them. “Your Medicine: Play It Safe” is available through the National Council on Patient Information and Education and the Agency for Healthcare Policy and Research by calling (301) 656-8565 or by visiting www.talkaboutrx.org
• Take an inventory of a patient’s medications. Have patients bring in all of their medications, including over-the-counter drugs and those prescribed by other physicians. Designate a special place for a detailed medication history in charts.
• Providing accurate and usable drug information to all healthcare professionals involved in the medication use process reduces the number of preventable ADEs. Not only should drug information be readily accessible from various sources such as drug references, formulary, protocols, dosing scales, but also the drug information must be up-to-date and accurate.
• Staff education should focus on priority topics, such as: new medications being used in the hospital, high-alert medications, medication errors that are known to have occurred both internally and externally, protocols and policies and procedures related to medication use.
• The FDA encourages healthcare professionals to report any actual or potential medication errors to the agency’s MedWatch Adverse Reporting System online at www.fda.gov/medwatch/, by phone at (800) 332-1088 or by fax at (800) 332-0178. Caller identification is kept confidential and is protected from disclosure by the Freedom of Information Act.

For tips provided to pharmacists on how they can reduce medication errors, visit the Pharmacist Education section.