Type your tag names separated by a space and hit enter

Medication Errors: Improving Practices and Patient Safety

Medication Errors: Improving Practices and Patient Safety is a topic covered in the Davis's Drug Guide.

To view the entire topic, please or purchase a subscription.

Anesthesia Central is an all-in-one web and mobile solution for treating patients before, during, and after surgery. This collection of drug, procedures and test information is derived from Davis’s Drug, MGH Clinical Anesthesia Procedures, Pocket Guide to Diagnostic Tests, and MEDLINE Journals. Explore these free sample topics:

Anesthesia Central

-- The first section of this topic is shown below --


It is widely acknowledged that medication errors result in thousands of adverse drug events, preventable reactions, and deaths per year. Nurses, physicians, pharmacists, patient safety organizations, the Food and Drug Administration, the pharmaceutical industry, Health Canada, and other parties share in the responsibility for determining how medication errors occur and designing strategies to reduce error.

One impediment to understanding the scope and nature of the problem has been the reactive "blaming, shaming, training" culture that singled out one individual as the cause of the error. Also historically, medication errors that did not result in patient harm–near-miss situations in which an error could have but didn't happen–or errors that did not result in serious harm were not reported. In contrast, serious errors often instigated a powerful punitive response in which one or a few persons were deemed to be at fault and, as a result, lost their jobs and sometimes their licenses.

In 1999, the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System, which drew attention to the problem of medication errors. It pointed out that excellent health care providers do make medication errors, that many of the traditional processes involved in the medication-use system were error-prone, and that other factors, notably drug labeling and packaging, contributed to error. Furthermore, the IOM report, in conjunction with other groups such as the United States Pharmacopeia (USP) and the Institute for Safe Medication Practices (ISMP), called for the redesign of error-prone systems to include processes that anticipated the fallibility of humans working within the system. This initiative is helping shift the way the health care industry addresses medication errors from a single person/bad apple cause to a systems issue.

The National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) developed the definition of a medication error that reflects this shift and captures the scope and breadth of the issue:

"A medication error is 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."

Inherent in this definition's mention of related factors are the human factors that are part of the medication use system. For example, a nurse or pharmacist may automatically reach into the bin where dobutamine is usually kept, see "do" and "amine" but select dopamine instead of dobutamine. Working amidst distractions, working long hours or shorthanded, and working in a culture where perfection is expected and questioning is discouraged are other examples of the human factors and environmental conditions that contribute to error.

The goal for the design of any individual or hospital-wide medication use system is to determine where systems are likely to fail and to build in safeguards that minimize the potential for error. One way to begin that process is to become familiar with medications or practices that have historically been shown to be involved in serious errors.

-- To view the remaining sections of this topic, please or purchase a subscription --


Quiring, Courtney, et al. "Medication Errors: Improving Practices and Patient Safety." Davis's Drug Guide, 16th ed., F.A. Davis Company, 2019. Anesthesia Central, anesth.unboundmedicine.com/anesthesia/view/Davis-Drug-Guide/110085/all/Medication_Errors:_Improving_Practices_and_Patient_Safety.
Quiring C, Sanoski CA, Vallerand AH. Medication Errors: Improving Practices and Patient Safety. Davis's Drug Guide. 16th ed. F.A. Davis Company; 2019. https://anesth.unboundmedicine.com/anesthesia/view/Davis-Drug-Guide/110085/all/Medication_Errors:_Improving_Practices_and_Patient_Safety. Accessed April 23, 2019.
Quiring, C., Sanoski, C. A., & Vallerand, A. H. (2019). Medication Errors: Improving Practices and Patient Safety. In Davis's Drug Guide. Available from https://anesth.unboundmedicine.com/anesthesia/view/Davis-Drug-Guide/110085/all/Medication_Errors:_Improving_Practices_and_Patient_Safety
Quiring C, Sanoski CA, Vallerand AH. Medication Errors: Improving Practices and Patient Safety [Internet]. In: Davis's Drug Guide. F.A. Davis Company; 2019. [cited 2019 April 23]. Available from: https://anesth.unboundmedicine.com/anesthesia/view/Davis-Drug-Guide/110085/all/Medication_Errors:_Improving_Practices_and_Patient_Safety.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Medication Errors: Improving Practices and Patient Safety ID - 110085 A1 - Quiring,Courtney, AU - Sanoski,Cynthia A, AU - Vallerand,April Hazard, BT - Davis's Drug Guide UR - https://anesth.unboundmedicine.com/anesthesia/view/Davis-Drug-Guide/110085/all/Medication_Errors:_Improving_Practices_and_Patient_Safety PB - F.A. Davis Company ET - 16 DB - Anesthesia Central DP - Unbound Medicine ER -