Reduce Your Risk of Medication Errors

photo pile of pills - risk of medication errorsMedications can make you feel better and can save your life. However, medications can also make you sicker – particularly if you take the wrong medication or take a medication differently than your doctor prescribed. Medication errors occur in hospitals, care facilities and at home. Learning how to reduce your risk of medication errors can help you feel better and might save your life!

How serious are medication errors?

Medication errors can lead to serious health consequences and even death.

Medication Issues in Hospitals

photo old man in nursing home - risk of medication errorsPatients frequently take medications while in the hospital. In fact, the average patient takes 10 different medications. Given the quantity of medications being dispensed, and the fact that many pills look alike or have similar sounding names, it’s easy to see that without proper safeguards, busy staff members could easily give patients the wrong medications or the wrong dosage.

How common are medication errors in hospitals?

Very! The Institute of Medicine estimates the average hospitalized patient experiences at least one medication error each day! This IOM report also states there are 1.5 million preventable adverse drug interactions each year in US hospitals and long-term care facilities.

What kinds of medication errors are common in hospitals?

The Institute for Safe Medication Practices recently published a “top ten” list of the most persistent medication errors and safety issues. Each of these issues can lead to patients receiving the wrong medication or wrong dosage, and/or receiving medication at the wrong time. Their list focuses on medication safety issues that are:

  • Frequently reported.
  • Caused serious harm to patients.
  • Could be avoided or minimized with system and practice changes that can be achieved by all healthcare providers.

Here are 4 of the top 10 errors (you can read the full list here):

Selecting the wrong medication on a computerized order system. 

photo doctor on laptop - reduce risk of medication errorsRemember when doctors scribbled medication orders on a piece of paper? This old-fashioned ordering left a lot of room for errors as pharmacists had to decode illegible scrawl. One would think that ordering medications electronically would eliminate ordering problems, but these systems are far from error-proof. In fact, errors resulting from electronic ordering may be as common, if not more common, than when doctors hand wrote orders. How? When doctors type the first few letters of a drug name, the computer presents a list of medications that start with the given letters. If the doctor is not paying close enough attention, he/she can easily choose the wrong medication. And these ordering systems make it easy for doctors to select the wrong dosage as well.

Confusing medications due to look-alike labeling of products.

Many medication packages and labels look similar, which can lead to choosing the wrong medication. Pharmaceutical companies increasingly use highly stylized graphics, along with prominent corporate names and logos, that can make it hard for healthcare providers (and patients) to see important information. This problem is made even worse by the use of similar labels and cap colors, which can make different products look alike.

Misheard drug orders or recommendations during verbal/telephone communication. 

photo of woman listening with hand to earDid you play the game “telephone” when you were young? The game was (and still is!) fun because the phrase uttered by the last person usually differed significantly from the starting phrase. What’s not fun is getting the wrong medication because the pharmacist couldn’t hear or understand verbal instructions regarding a medication order. Although most medications are now ordered electronically, there are still situations that require doctors to order a medication in-person or on the phone. For instance, doctors may verbally request medications when an emergency arises during an operation or procedure. If the pharmacist doesn’t correctly hear the name or dosage, he/she may dispense the wrong medication.

Unsafe “overrides” with automated dispensing cabinets (ADCs).

Most hospitals use automated dispensing cabinets for most of the medications dispensed. Although you would think these “smart” cabinets would prevent errors, that is not the case. Unfortunately, it’s usually easy for healthcare workers to override the system, dispensing medications without a review from a pharmacist, which can lead to patients receiving the wrong medications.

Medication Issues at Home

Taking charge of your own medications does not necessarily mean you are free from the risks of medication errors. In fact, research shows that more than 50% of US adults don’t take their medications as prescribed.

How often are patients harming themselves by taking the wrong medication?

To determine how big a problem medication errors are when patients are responsible for their own medications, outside of hospitals, researchers analyzed National Poison Database System (NPDS) data from 2000 through 2012. They found that during this period, there were 67,603 reported exposures related to medication errors that resulted in serious medical outcomes. They found a 100% rate increase during the 13-year study period.

My 2 cents: It’s hard to imagine that all medication errors are reported to the NPDS, so my intuition is that the number of incidents is likely much higher than what was reported in this study.

How do medication errors at home impact health?

The study found the impact on health was as follows:

  • 93.5% – Moderate effect
  • 5.8% – Major effect
  • 0.6% – Death

What kinds of medication errors are patients making at home?

The most common types of medication errors found in this study were:

  • Taking the incorrect dose.
  • Taking or administering the wrong medication.
  • Mistakenly taking a medication twice.

What kinds of medications are frequently causing serious outcomes?

The study found the following medication categories were most frequently associated with serious outcomes:

  • 20.6% – cardiovascular drugs (primarily beta blockers, calcium antagonists, and clonidine)
  • 12.0% – analgesics (most often opioids and acetaminophen, alone and combination products)
  • 11.0% – hormones/hormone antagonists (in particular, insulin and sulfonylurea).

Reduce Your Risk of Medication Errors

It cannot be overstated – you must pay attention to medication, whether you are in the hospital or at home. Follow my suggestions to reduce your risk of medication errors.

For hospitalized patients:

  • photo old woman in hospital - risk of medication errorsKeep at your bedside a complete list of all medications prescribed, as well as for over-the-counter medications.
  • Ask the staffer to confirm the name and dosage of each medication before it is taken.
  • If a staff member gives you a medication that doesn’t look familiar, do NOT take it without getting clarification. Ask to speak to the charge (head) nurse if you don’t think you should be taking a particular medication. If you don’t get an answer that seems logical to you, ask to speak to your doctor, or the doctor covering the floor.

For patients at home:

  • Always carry a complete list of medications you are taking, including over-the-counter medicines. Share this list with each doctor – don’t assume each doctor knows what other doctors have prescribed.
  • When your doctor prescribes a new medication, ask your doctor why, how and when to take any medications. Write this information down so you can refer to it later.
  • Be sure you are getting the right medication at the pharmacy – if a medication looks different than in prior refills, ask the pharmacist to confirm that you have the right one.
  • photo pill sorter with one slot open showing pillsOrganize your pills in a pill sorter – this will give you an easy visual cue as to whether or not you have taken your medication.
  • Set up a system to remind yourself to take your medications – set alarms on your phone. Leave medications where you will see them (but not in the bathroom where humidity can affect medications).

Learn more…

All medications have the potential to harm patients. And it’s critical to take the right medication, at the right time, in the right way. Read these blog posts to learn more to reduce your risk of medication related issues:


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