Account for 1 in 3 of all hospital AE

Ecah year in the US, 7K-9K die due to a medication error, and 7M are affected (Source, 2020). The most common reasons are communicate drug orders, illegible handwriting, wrong drug selection chosen from a drop-down menu, confusion over similarly named drugs, confusion over similar packaging between products, or errors involving dosing units or weight. A factor in 75% of these errors was distraction.

Out of all medication errors, prescription is often the most common error, 49% in this study, followed by dispensing (14%) and 23% in administration (Source, 2008). 42% of drug prescribing and 37% of dispensing errors were recovered while none were in the administration phase. Nurses were most likely to recover errors.

Common types of errors different from study to study. This study found 43% of errors stemmed from administration at the wrong time, 30% omission, 17% wrong dose (Source, 2002). Another study found wrong dosage (40%) and contradiction of medication (30%) common errors. (Source, 2011). 58% involved wrong doasge, 13% failure to recognize known allergies in this study (Source, 2001).

Dispensing errors occur 50M times in the U.S per year, with 50K causing harm (Source, 2009). Wrong label information and instruction were the most common cuases. Pharmicists may often give the wrong drug (32%), and causes were related to sound-alike drugs and near expired drugs (Source, 2020).

A seperate error that warrants great disscussion in communication of medical errors and next steps taken are MTEs. Around 52% of hospitals did not encourage reporting MTEs (Source, 2019). For MTEs, this study found 52% of errors resulted from ommision, 16% unauthorized medication, 7% alternative drugs, 7% requested more than required, 18% wrong dose. Transcription errors occur 12% of the time.

Prescribing errors should be the focus of many efforts as the result in the highest amount of errors. This study show ~20% of errors resulted from wrong dosage request, 19% due to ommited medicine, 7% for wrong frequency and drug, followed by 4% for contradicting drugs and wrong patient. Other errors are at a miniscule amount. (Source, 2017, UK)

• Story
• General Facts
• Where medication errors and likely and high risk
• Error Types ← link also applies to the 4 below
• Workload, time of day, shift
• Latent conditions that causes errors
• List of implentation ← reduce errors by 23% in chemo prescription
• Potential errors with computarized systems
• Medication Resources
• FDA on Medication Errors - Mainly around packaging design + review
• WHO Paper
• Florida Education Article