10 common medication errors
The most common types of medication errors include:
- Incorrect dosage: whether it’s an overdose or underdose, prescribing or administering the wrong dose can impact patient outcomes
- Incorrect patient: sometimes, paperwork errors can lead to the wrong patient being given someone else’s medication
- Repeated dosage: if the first dose isn’t properly logged, there’s a risk of the patient being given an extra dose
- Incorrect timing: consistency and timing is vital with many medications, so administering a dose after a meal rather than before food, or in the afternoon rather than upon waking can impact its effectiveness
- Administering the wrong medication: giving a patient the wrong medication altogether is another common error, and will require careful monitoring to assess the impact
- Wrong method of administration: incorrect dosage form or administration method can also hinder a medication’s effectiveness; for example, immediate release rather than extended release, or oral administration instead of intravenous administration
- Omission: missing a dose altogether can also be a common medication error
- Miscalculating a dose: it’s vital that all prescribing staff regularly refresh their training on how to calculate doses to prevent this cause of medication errors
- Failure to prepare: failing to prepare medication in the correct way can have consequences for the patient; for example, if a diluent is missed, the incorrect strength may be administered
- Failure to check allergies: missing a patient’s allergy status is another preparation error, and could have potentially fatal consequences
What to do if a medication error occurs
All pharmacists and healthcare professionals need to know what to do if there is a medication error to keep the patient safe, and ensure correcting reporting procedures are followed. Here’s what to do if a medication error occurs due to a mistake by you or a colleague:
1. Stay calm and professional
When a medication error occurs, it’s crucial to stay calm. You might feel worried, panicked or even embarrassed, but take a deep breath to keep yourself calm, so you can think clearly and stay professional.
It’s important to act quickly to minimise the impact on the patient, but keeping a calm demeanour will reduce the patient’s anxiety and ensure you can clearly communicate the incident to your colleagues. Remind yourself that everyone makes mistakes sometimes, and remember your training on what to do if a medication error occurs.
2. Assess the facts
Take a moment to review the facts, so you can assess the severity of the error and understand its potential impact. Try to identify why the error occurred and communicate this with colleagues in case there’s an issue that may affect other prescriptions on your shift.
Ascertaining as much information as possible means you can take the most appropriate next steps to mitigate the impact on the patient.
3. Put the patient first
Put your own feelings to one side and focus on the patient. They’ll need to be monitored closely to assess the impact, and you should let them and their loved ones know what’s happened. It’s important to be honest and open so they fully understand the situation, and what’s being done to address the incident.
Monitor the patient for signs of any adverse effects or reactions, and ensure the appropriate care is provided if necessary. Keep them informed and reassured, let them know the incident will be reported, and make sure they’re kept up to date throughout the investigation process.
4. Tell your supervisor
Any medication errors should be reported to your supervisor as soon as possible, and they should support you to deliver the necessary corrective action. Tell them exactly what’s occurred, including the nature of the error, when it occurred, how you realised, the immediate steps you’ve taken, and why you think it happened.
Most healthcare environments have a ‘no-blame’ culture, which focuses on addressing the issue, rather than on blaming the individual. Once the situation has been addressed and the patient is safe, take the time to speak to your supervisor about how similar incidents could be prevented in future.
5. Report the error
All medication errors must be documented and reported so they can be learnt from and future incidents can be prevented. The error must be documented in the patient’s medical record, with details on exactly what occurred, the effect on the patient, and what actions were taken. A formal incident report will also need to be completed, and serious or fatal errors may need to be reported to the Care Quality Commission (CQC).
How to report a medication error
The medication error reporting procedure may vary from Trust to Trust, but regardless of the process, incidents should be reported as quickly as possible, with key learnings communicated widely. Reporting plays a key role in identifying any patterns and preventing future medication incidents.
When reporting medication errors, make sure you follow these steps:
- Write a detailed medication error reflection that outlines exactly what happened – this is why it’s so important to stay calm in the first instance, so you can recall the details
- Stay focused on the system and the process, rather than placing blame on any individual person
- Involve the patient in the reporting process as much as possible. They’ll be best-placed to describe the impact of any adverse effects, and will also be able to provide extra detail on how the incident was initially dealt with
- Find out whether the error needs to be reported externally. Serious or fatal incidents will need to be reported to the CQC
- Know where the incident report needs to be stored and who requires access
- Make sure there are steps in place to facilitate change and drive improvement to prevent medication errors in the future
How to write a medical error statement
When writing a medical error statement, it should include the following sections:
- Introduction: start by detailing your name, role, training and qualifications, and why the statement is being written
- Incident description: clearly describe exactly what happened and when, and what the immediate impact was
- Steps taken: provide a detailed account of the action taken, including who was informed and when, how the patient was told, and how they were monitored afterwards
- Reflection: finish with a conclusion that includes reflections on why you believe the medication error occurred, and what you think should be done to prevent similar incidents in the future
How to prevent medication errors
In 2014, NHS England introduced the Medication Safety Officer role to improve the reporting and investigation of medication errors, and to examine how they can be learnt from to prevent future incidents.
Raising awareness and ongoing education are key to preventing medication errors. The York and Scarborough Teaching Hospitals NHS Foundation Trust conducted a literature search to explore the different methods used to learn about and prevent medication errors in the UK, finding that a variety of approaches are used to appeal to different learning styles.
1. Share incident bulletins
Incident bulletins are commonly used to share learnings following medication errors, but it’s important to ensure these are available both digitally and via hard copies to capture healthcare staff who don’t have time to check their emails.
A study of an email medication safety bulletin at the Royal Cornwall Hospital showed that there was enthusiasm for this type of intervention. However, it was suggested that this learning could be improved by distributing hard copies to wards, and linking this with face-to-face feedback by pharmacy staff at ward level.
2. Pre-round safety huddles
Safety huddles are becoming established practice in healthcare, with one study showing awareness of safety issues subsequently improving by up to one-third. Conducting these prior to a ward round can be a time-efficient communication method to improve knowledge around safety projects.
York and Scarborough Teaching Hospitals NHS Foundation Trust piloted a series of monthly medication messages focusing on medication-related Never Events and high-risk medicines. A short summary was prepared for inclusion at safety huddles, with key messages for prescribers and nursing staff. Supporting information in the form of a bulletin was also sent to the ward for email distribution, and hard copies were provided for staff rest rooms and notice boards.
3. Safety talks on the wards
It can be challenging for staff to leave the ward for training, but another option is for members of the medication safety team to visit wards to talk about specific safety issues, following this up with printed information. Although this may be ad hoc and relatively informal, taking education to ward-based teams tends to be well-received.
4. Education sessions
Ongoing education and training are key to preventing medication errors, and incidents must be learned from in order to prevent future occurrences. Alongside formal teaching on set topics, informal lunchtime learning sessions can also provide a good forum for knowledge sharing and updating training. These sessions can provide an opportunity to discuss recent medication incidents, raise areas of concern, and suggest solutions.
5. Individual feedback
Providing feedback on prescribing errors may also help to prevent future medication errors. Individual feedback should form part of incident investigations, but feedback to prescribers can be sporadic, as often the original prescriber is not on the ward when the incident is discovered.
Ideally, all medication incidents should be fed back and reflected on in prescriber portfolios. Researchers at the University of Exeter developed a toolkit and self-assessment framework for optimising feedback conversations, while another option is to introduce a ‘pharmacist buddy’ system to encourage regular, supportive catch-ups regarding any incidents.
Join the UKCPA Medication Safety Pharmacy Community
Share your own learnings and build your prescribing confidence to help prevent medication errors when you join the UKCPA Medication Safety Pharmacy Community for less than £3 per week. Become a member today to:
- View an extensive medicines safety resource library
- Participate in dedicated medication safeguarding forums
- Access medication safety training led by experts in the field
- Attend in-person and virtual networking events to share learnings with fellow pharmacists
Further reading
- Ciapponi et al. Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews; 2021; (11), pp. CD009985.
- Hayman S et al. Learning from medication errors: The ‘bulletin’ as a communication tool. International Journal of Pharmacy Practice. Conference: Royal Pharmaceutical Society Conference 2011. 19(SUPPL. 2) (pp 65).
- Flaherty B et al. Evaluation of a daily pre-round huddle to improve knowledge of safety and QI projects. Critical Care Medicine. Conference: 50th Critical Care Congress. 2021; 49(1 SUPPL 1) (pp 560).
Acknowledgements
Parts of this article are based on an original review published in 2022 by Helen Holdsworth, Medication Safety Officer and Deputy Chief Pharmacist at York and Scarborough Teaching Hospitals NHSFT.
The article does not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
