Medication Administration Errors

Background
Medication errors have been a key target for improving safety since Bates and
colleagues' classic reports in the 1990s describing the frequency of adverse drug
events (ADEs) and the relationship between medication errors and ADEs in
hospitalized patients. As described in related primers on medication errors and
adverse drug events and on the pharmacist's role in medication safety, there are
multiple steps in the pathway between a clinician's decision to prescribe a
medication and a patient's receipt of that medication. This primer will focus on
errors in the administration of medications, the final step in medication pathway.
Errors in medication administration can occur through failures in any of the five
rights (right patient, medication, time, dose, and route). Such errors may be the
result of individual-level slips and lapses, but may also result from system-level
failures such as understaffing, human factors problems (e.g., poor process or
equipment design), and other latent conditions.
Despite considerable error reduction efforts—including both process changes and
the implementation of new technologies—medication administration errors remain
a serious safety problem. In a review of 91 direct observation studies, investigators
estimated median error rates of 8%–25%, depending on the measurement
strategy and whether or not timing errors were included. Intravenous
administration was even more error-prone, with an estimated median rate
(including timing errors) ranging from 48%–53%. One study estimated a 73%
probability of at least one error occurring during a single given intravenous
medication administration. The most common type of error was wrong time of
administration, followed by omission and wrong dose, wrong preparation, or
wrong administration rate (for intravenous medication).
A substantial proportion of medication administration errors occur in hospitalized
children. This is not surprising, as the greater complexity of pediatric dosing (often
based on weight or body surface area) increases the risk for errors in prescribing
and administration. Another substantial source of medication administration error
is patients and caregivers, who are responsible for the vast majority of medication
administration at home. A review of 36 studies on caregiver medication errors
found error rates ranging from 2%–33%, with dosage errors, omissions, and
wrong medication the most common types of administration errors. Low health
literacy, poor provider–patient communication, and absence of health
literacy universal precautions contribute to self- and caregiver medication errors.

Prevention
In inpatient settings, interventions to prevent medication administration errors
include use of technology such as barcoding for medications and patients, smart
infusion pumps for intravenous administration, single-use medication packages,
and package design features such as Tall Man lettering. Because interruptions
during the medication administration process are common and associated
with increased risk and severity of errors (even after controlling for nurse and
hospital characteristics), minimizing interruptions during the medication
administration process has also been a strong focus for error reduction. However,
few of these interventions is likely to be successful in isolation, and efforts to
improve safe medication use must also focus on transitions to home, primary
care, and patient and caregiver understanding and administration of medications.
Barcode medication administration (BCMA) technology can essentially eliminate
wrong patient, medication, and dose errors in inpatient settings. A classic study of
nontiming medication errors in a system with comprehensive barcoding/electronic
medical administration technology found a 41% reduction in errors and a 51%
decrease in potential adverse drug events. Timing errors were also reduced by
27% in this institution.
In theory, BCMA reduces the opportunity for error by using barcode labeling of
patients, medications, and medical records to electronically link the right dose of
the right medication to right patient at the right time. However, BCMA is subject to
a number of usability issues and workarounds that can degrade its effectiveness in
practice. Users may encounter blockades in the BCMA workflow, for example,
when the patient's arm band is not readable, the medication is not labeled or not
in the system, or the scanning equipment malfunctions. A Dutch studyusing direct
observation in four hospitals found nurses used workarounds to solve BCMA
workflow blockades in more than two-thirds of medication administrations, and
workarounds were associated with a threefold higher risk of medication error.
Although smart infusion pumps offer numerous safety advantages, they are also
prone to implementation and human factors problems, such as difficult user
interfaces and complex programming requirements that create opportunity for
serious errors.
A systematic review of interventions to decrease nursing interruptions during
medication administration found weak evidence of effectiveness, and a
randomized feasibility study of a "do not interrupt" bundle found that though the
bundle was moderately effective, it had limited acceptability and sustainability. A
related primer on health literacy outlines some of the difficulties patients and family
members encounter in understanding their medication regimen, as well as
interventions for improving communication and understanding.

Current Context

Experts on medication administration errors note that progress in the field is

hindered by lack of consensus on operational definitions used to classify
medication administration errors, along with wide variation in measurement
strategies. Furthermore, steps in the medication pathway are complex and
interconnected. Substantial improvements in medication safety likely require a
comprehensive, systems-oriented approach that integrates all aspects of the
medication pathway from initial therapeutic decisions in primary, specialty, or
inpatient care, to medication use in the community by patients and families.