Medication Errors: Safe Strategies for Avoiding Them


What’s causing medication errors, and what can your facility do to mitigate the risk of errors?  

An erroneous formulation. An incorrect label. The wrong frequency. These are some of the many ways that medication errors can happen.  

And they do happen, frequently. According to the U.S. Food and Drug Administration, the FDA receives more than 100,000 reports each year associated with a suspected medication error.  

Of course, it’s not simply a matter of carelessness or ineptitude. Experts attribute medication errors to a number of factors, some of which are well beyond the average healthcare professional’s control.

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Continuity concerns 

The modern healthcare system has gotten increasingly complex over time. In many cases, patients are no longer firmly at the center of this system, which is one of various factors contributing to an environment where mistakes are more likely to occur, says Teri Dreher, RN, CCM, BCPA, owner and founder of NShore Patient Advocates in Chicago.  

“Hospitals are trapped between tight financial constraints and attending to patients,” she says, adding that facilities are also often under pressure to quickly discharge patients, sometimes too quickly, in order to free up beds.  

“Many hospitals are chronically understaffed with regard to nurses — the patient’s primary point of contact — and support staff such as janitors, who are charged with the very important job of keeping the hospital clean.” 

Physicians frequently find themselves in similar circumstances — spending hours documenting health records and completing insurance forms. This time was once spent on patients, says Dreher. 

“At the same time, they’re reimbursed by health insurers at ever-shrinking rates, even as their malpractice insurance premiums soar,” she continues. “This is why many doctors are increasing their patient load. [The] end result is less one-on-one time with patients and a greater risk of something falling through the cracks.”  

Drivers of medication errors 

Deborah Sadowski, RPh, MHA, director of pharmacy services at Deborah Heart and Lung Center in Browns Mills, N.J., points to three primary drivers of medication errors in the current healthcare environment.  

Transition of care, for example, can include movement within one facility — from admission, from one unit to another, or at discharge — or between facilities. These moves open patients up to risk for errors, says Sadowski.  

Discharge from a hospital, for instance, is a very intricate process. “[This is] a high vulnerability point in a patient’s care related to clear communication and understanding of relevant information at the time of hand-off to the new caregivers, be it at another healthcare facility or the patients themselves,” says Sadowski. “It is essential that there be clear and effective provider communication at every step in this process . This assures that medications are continued, stopped, or changed appropriately.” 

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Drug shortages  

Indeed, continuity is critical in maintaining medication safety. As is standardization, says Sadowski, pointing out that the growing number of drug shortages adds to the potential for more medication errors and poorer patient outcomes.  

“This occurs because the healthcare team may be forced to use medications in different concentrations or dosage forms than the standards they are used to. They may even use alternative, less familiar drugs that might be second-line choices for the desired therapy,” she continues. “These can lead to near misses, errors or even adverse outcomes, despite everyone’s best efforts.” 

Staffing shortages 

Unfortunately, best efforts are not always enough. Increasing rates of burnout are leading to staffing shortages, which places tremendous pressure on the entire healthcare industry. 

“The COVID-19 pandemic has put extreme stress on the health care workforce in the United States, leading to workforce shortages as well as increased health care worker burnout, exhaustion, and trauma,” reads a report from the U.S. Office of Health and Human Services. According to the United States Registered Nurse Workforce Report Card and Shortage Forecast published in the September/October 2019 issue of the American Journal of Medical Quality, a shortage of registered nurses is projected to spread across the country through 2030. 

The strain that these exacerbated staffing issues put on healthcare workers “can have a detrimental effect on patient safety if pushed too far,” says Sadowski.  

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Preventing medication errors before they happen 

The U.S. Food and Drug Administration has taken steps to help minimize the number of drug shortages. 

Title X of the Food and Drug Administration Safety and Innovation Act (FDASIA) provided the FDA new authorities designed to help the agency combat drug shortages, such as broadening the scope of the early notification provision by requiring all manufacturers of certain medically important prescription drugs to notify the FDA of a permanent discontinuance or a temporary interruption of manufacturing.  

FDASIA also required the FDA to issue a non-compliance letter to manufacturers that fail to comply with the drug shortage notification requirements. If the company does not have a reasonable basis for failing to comply, they must make the letter and the company’s response available to the public.  

Pharmacies, healthcare facilities, and healthcare professionals must keep an eye on drug shortage reports from organizations such as the FDA or the American Society of Health-System Pharmacists (ASHP). This can help in managing drug supply based on the most recent information, says Sadowski.  

Strategies to cut down prescription errors 

To help cut down on shortage-related prescription errors, she recommends strategies such as:

  • Therapeutic substitutions
  • Changing IV medications to oral dosage forms when possible
  • Considering transitions to non-pharmacologic interventions when shortages occur

Beyond addressing ongoing drug shortages, healthcare professionals can take other steps to reduce the likelihood of medication errors. This starts at the prescription phase. Important steps include: medication reconciliation at transition of care and computerizing order entry to eliminate the risk of human error.  

Clinical pharmacists should also oversee the dispensing of medications. “Tall-man” lettering is a good way to minimize confusion between medications that look or sound alike, for instance.  

Ultimately, the implementation of — and strict adherence to — critical protocols is a carefully coordinated, multi-step process that requires communication throughout the healthcare system, says Sadowski. “Collaboration among healthcare professionals is essential. Communication assures that all parties have access to accurate information. This means that all can work together for the best care of our patients.”