Clearly, no one wants to get sicker while they are in the hospital. And certainly, no one wants to take a medication that could harm them. It would be easy to assume that your nurse is giving you the right medication at the right time, but unfortunately that is not always the case. Medication errors in hospitals are common and can be dangerous.
Since most hospitalized patients receive medication, it’s important for hospitals to have robust programs to avoid medication errors. But how can hospitals reduce medication errors? What can you do to protect yourself or a loved one?
How common are medication errors in hospitals?
Researchers conducted a systematic review and meta-analysis of 20 years of scientific research. Their 2019 report shows that medication-related errors were the most common cause of preventable patient harm (followed by surgical procedures, healthcare infections and diagnostic errors).
Additionally, a 2006 landmark report by the Institute of Medicine estimates at least one medication error per patient every day in hospitals and long-term care facilities! The report also states that each year there are 1.5 million preventable adverse drug interactions in US hospitals and long-term care facilities.
Yes, this report is over 14 years old. And improvements to ordering methods, as well as hospital efforts to reduce medication errors, have likely reduced the number of errors. However, there is still much room for improvement.
Error rates might increase in 2022.
A 2021 analysis by Forrester estimates that the high turnover rate of medical professionals, combined with continued burnout among staff, will contribute to “irreversible patient impacts” such as adverse drug reactions due to medication errors and administrative flaws. Therefore, patients will be at higher risk for worsening health and death.
How dangerous are medication errors?
Medication errors can cause a range of patient harm, including death.
What kinds of medication errors occur?
Medication errors include patients getting the wrong drug, the wrong dosage, drug overdoses, and overlooked drug interactions and allergies.
How do these mistakes happen?
Opportunities for errors exist at many places along the way, including:
- Doctors* can make mistakes when ordering medication. He/she can order the wrong medication – which can happen more easily than you think because many medications have similar name. Similarly named medications also make it easier for doctors to choose the wrong drug on a drop-down menu on a computerized ordering system. Or, doctors can order the incorrect dosage, due to mathematical errors, a misplaced decimal point, or other mistakes.
- Pharmacists can misread the prescription, especially if it is handwritten. Additionally, the pharmacist can select the wrong medication or wrong dosage due to confusion over drugs with similar names or with similar packaging. And pharmacists can pick the right medication but the wrong dosage. Lastly, the pharmacist can mix up patients and provide one patient with another patient’s medication.
- Nurses can give a medication to the wrong patient, or give a medication at the wrong time. Additionally, nurses can program a medication pump incorrectly, which can lead to medication being given too quickly or too slowly.
*Although nurse practitioners and other health professionals prescribe medications, for ease of reading, the term “doctor” refers to all who prescribe medications.
Infusion pump errors are common.
Infusion pumps, used to administer medications as well as other fluids and nutrients are essential for patient care. These pumps, which administer medications intravenously, are associated with a high frequency of adverse events.
Researchers evaluated infusion pump errors in 2018 in Pennsylvania hospitals and found that 99% of the adverse events were identified as “incidents” – meaning they adversely affected a patient. Fortunately, only 1% were deemed “serious events”.
Importantly, 85% of these infusion pump errors reached the patient – for instance, the patient received the wrong medication, the wrong dosage, or received the right medication at the wrong speed. Alarmingly, 22% of the cases involved high-alert medications.
The research team identified the following sources of infusion pump errors:
These errors occur when nurses enter an incorrect setting or value into an infusion pump interface. Errors can result from a range of reasons, including:
- Miscalculating dosage due to either using an incorrect patient weight.
- Calculation errors due to using incorrect units of measure.
- Failing to enter the proper rate of administration.
- Entering too few or too many digits (e.g., entered 0.2 instead of 0.02 or 488 instead of 48).
- Entering a value in the wrong field.
- Failing to choose the correct medication.
- Entering drug information into incorrect pump channel.
- Failing to start the pump.
Interestingly, 19% of errors were due to programming the wrong speed (or rate) of medication flow.
Pre-administration process problems.
Even before the pump is programmed, process problems can occur that lead to medication errors. For example, the pharmacy may prepare the wrong medication due to an incorrect order, a transcription error, or by making an error while preparing a medication. These errors can lead to patients receiving the wrong medication, or the wrong rate or dose.
Errors can occur when nurses fail to correctly connect or clamp IV tubing. Examples include connecting IV tubing to the wrong access port, connecting tubing into the wrong medication bag, or failing to close or open the tubing clamp.
Sometimes, even when everything is set up correctly, the pump or tubing valve can malfunction.
Pump maintenance issues.
If devices are not maintained properly, they can malfunction.
Patients intentionally or unintentionally adjusting programming of the pump, leading to medication errors.
Some good news.
Modern infusion pumps, sometimes called smart pumps, incorporate numerous features designed to prevent various types of use errors. Ask your hospital if they use smart pumps, which can reduce your risk of medication errors.
Computerized order systems can reduce the risk of medication errors.
Medication errors may be due to human mistakes, but a well-designed computerized physician order entry system (CPOE) can potentially detect mistakes and prevent harm.
Not only do these systems eliminate mistakes associated with doctors’ notoriously bad handwriting, but they can also detect errors as doctors enter orders.
How? The orders are automatically checked for potential errors or problems, based on integrated patient information, including information on lab results, allergies, and medications currently taken by the patient.
Specific benefits of CPOE systems include:
- The doctor receives a warning when there is a possibility of a drug interaction, allergy, or overdose.
- Drug-specific information that eliminates confusion among drugs with similar names.
- Accurate, current information helps doctors keep up with new drugs.
- Improved communication between physicians and pharmacists.
- A reduction in healthcare costs.
How much can CPOE systems help?
According to a 2020 report by The Leapfrog Group, CPOE systems lead to significant reductions in serious medication errors. Furthermore, the report states that using CPOE systems at all non-rural US hospitals could prevent 3 million adverse drug events each year.
More good news about CPOE systems:
- A study at Boston’s Brigham and Women’s Hospital found that CPOE systems reduced error rates by 55%. A subsequent study by the same group found that serious medication errors fell by 88%.
- Another study conducted at Salt Lake City’s LDS Hospital showed a 70% reduction in antibiotic-related adverse drug events after implementing a decision support tool for antibiotics.
Electronic ordering systems are not perfect!
Although CPOE systems are very helpful, they are far from perfect. It’s still possible for doctors and pharmacists to make mistakes, leading to potential harm from medication errors. A few examples:
Failure to alert doctors to potential dangers.
These systems should alert a doctor if there is a potential problem in a medication order which could harm the patient, such as possible dangerous interactions.
However, the computer algorithms that detect potential issues are only as good as the data behind them. And that is a problem.
In a survey of American Society of Clinical Psychopharmacology members, 1/3 reported their e-prescribing system has given erroneous warning information. And 1/3 of those doctors stated the alerts were inaccurate 50% or more of the time.
Additionally, a study of electronic health records (EHRs) used in hospitals to order medication found that safety issues persist. In 2018, the EHRs only correctly identified safety issues 66% of the time. Although the 2018 results are better than in 2009 (with 54% correct), it’s still far from 100%.
Importantly, researchers found that these systems detected 98% of drug allergy information in 2018 but were less successful identifying drugs that would harm patients based on their diagnosis.
It’s too easy to make a mistake.
Interestingly, the #2 hazard in ECRI’s list of top technology hazards for 2021 relates to computerized medication ordering, storage and delivery systems. Specifically, the issue relates to how doctors choose a medication.
To make drug searching and selection faster and easier, many EHR and CPOE medication systems allow the doctor to enter only a few letters of a drug name before the system provides a list of drugs from which to choose.
This feature, designed for convenience, displays similar-looking drug names as options, increasing the risk of mistakenly selecting the wrong medication. Unfortunately, the Institute for Safe Medication Practices reports that medication selection errors associated with the display of similar-looking drug names has led to severe harm or death in several cases.
Interestingly, the ECRI report states that requiring at least 5 letters, instead of 3, would greatly reduce the number of matches and thereby significantly reduce the risk of errors.
An ECRI analysis of drug names found that 92% of FDA-approved drugs have the same first three letters as at least one other drug, compared with only 58% which share the first five letters with other medications.
Other medication safety issues related to electronic health records (EHRs).
Researchers for the Pew Charitable Trusts identified 12 ways in which EHRs can lead to medication safety issues in hospitals. Although this research focused on pediatrics, it is clear that these issues could impact patients of all ages.
Here are 9 of the issues (for more information on all 12 issues, read the report):
- If a doctor enters information in a field that isn’t visible to a nurse, errors can occur.
- Dosages for children are often based on the patient’s weight, but if staff use the wrong units to enter the weight (kilos vs pounds), dosage errors occur.
- Poorly designed information displays, including a failure to show an upcoming dosage, can lead to missed medications.
- When patients relocate within the hospital, staff must remember to remove an automatic medication hold. If the hold isn’t removed, doses can be missed.
- EHRs can have built-in processes, with automated medication schedules, that doctors cannot override, leading to medication errors.
- Doctors can order recurring doses of medication at specific times or intervals. But system defaults can override these instructions without staff realizing it, causing patients to get medications at the wrong time.
- EHRs may have hidden preset medication order settings that calculate the quantities of drugs needed, which can cause the patient to receive the wrong dosage.
- EHRs are designed to protect patients from allergic reactions and adverse drug interactions. When doctors order new medications, EHRs should warn doctors about potential dangers. However, in certain circumstances, this warning system can fail, potentially causing serious harm.
- Although EHRs can classify medications as needed for an indefinite amount of time or for a specified period, some EHRs don’t allow doctors to clearly distinguish between these two types of orders. This can lead to the automatic discontinuation of a needed medication.
Bedside barcoding can reduce medication errors.
In order to reduce the risk of medication errors, hospitals may scan both a bar code on a patient’s ID bracelet along with a bar code on the medication container (e.g. pill bottle or IV bag). If the bar codes do not match, an error signal alerts staff there is a potential issue, allowing nurses and doctors to confirm they have the right patient, right medication, and right dose.
What is your hospital doing about medication errors?
Certainly, your chance of experiencing medication errors is reduced if you stay at a hospital that uses a CPOE system and bedside barcoding. But, just having the technology is not enough.
For instance, a CPOE system must include software to prevent errors and should be used by all prescribers. Additionally, the system should be fully integrated into the patient health records.
How does your hospital rate on CPOE system use? Use Leapfrog’s Hospital Safety Grade website to evaluate hospitals. Enter your city/town or zip code to see a list of hospitals in your area. Select the ‘Practices to Prevent Errors’ tab and you will see the score for ‘Doctors order medications through a computer’.
No hospital will ever be completely error proof.
With so many possible ways hospital staff can make medication errors, it is obvious that CPOE and barcoding systems are not going to eliminate all errors. Doctors, nurses, and pharmacists are all humans, and humans make mistakes. Period.
What can you do to reduce your risk of medication errors in hospitals?
Because medication errors can be harmful, and may even cause death, you cannot assume that everything is A-OK. Try to use a hospital that has a strong CPOE program, and uses newer, smart infusion pumps. Importantly, the best strategy is to remain alert and speak up if you suspect an issue.
I suggest you follow these recommendations:
- Make sure all your nurses and doctors know about allergies and/or side effects you’ve experienced from medications.
- Keep a complete list of all medications you take, including over-the-counter medications, at your bedside. Share this list with your nurses and doctors. Update your list as doctors prescribe new medications.
- Create a schedule on paper that shows your medications and when you should take them. When a nurse is giving you medications, make sure you are getting the right medications at the right time.
- Don’t be afraid to ask the nurse what medications he/she is giving you. Medication containers should have a label that includes the name and dosage of the medication. If you do not see a label, or have any concerns, ask your nurse what the medicine is.
- If something doesn’t look or sound familiar, do not take it! Likewise, if it’s not the right time of day, don’t take it! Ask to speak to your doctor, or the attending nurse, before taking it. Since your life may depend on it, it’s critical that you stand your ground!
- Ask your nurse if any of your medications are considered “high-alert”. These medications, such as insulin and blood thinners, must be given the right way at the right time. If any of your medications are high-alert, ask what steps staff take to make sure you get these high-alert medications in the proper manner and time.
- Never take any medications you brought with you from home without discussing it with your doctor and nurse. You could develop an adverse drug reaction or other issue.
Want to learn more?
To learn about one patient’s multiple experiences with medication errors, read One Patient’s Tale of Medication Errors in Long-Term Care.
Additionally, read these posts for more information on medication safety:
- Reduce Your Risk of Medication Errors.
- What’s an Adverse Drug Reaction?
- Dangers of Black-Market Medications – More Common Than you Think.
- Tips to Take Medication as Prescribed.
- Are Antibiotics Helpful or Harmful? What You Need to Know.
- Doctors Prescribe Too Many Medications.
- Is Off-Label Medication Safe?
- Are Medications Safe?
NOTE: I updated this post on 3-30-22.