The most common errors were: improper dosage (%), wrong medication ( %), . The analysis of the routes of drug administration is shown in Figure 2. Wrong indication for dosage form, Divalproex for acute oral loading dose of valproic acid Table 2. Medications Involved in Dosage Form Prescribing Errors . writingdesk.pwceutical preparations - administration and dosage. writingdesk.pw writingdesk.pw 4. Safety. 5. .. Wrong dosage causes short-term toxicity or treatment failure. For.
Improper Dosage 2.
Staff pharmacists routinely utilized all available information resources to evaluate medication orders for appropriateness. Following the identification of medication orders potentially in error, the pharmacist contacted the prescriber or a cross-covering provider to obtain additional information and to discuss the orders in question.
Potential prescribing problems were defined as medication orders that involved: The medication order s in question were either confirmed as correct as written, or were clarified, changed, or discontinued following the discussion between the pharmacist and the physician. This secondary review was to ensure that the proper actions were taken and to assure provision of appropriate therapy. The significance of each error was determined based on the general potential of the error to be carried out, and if carried out as ordered, to result in adverse consequences, either an increased risk of adverse effects or an inadequate therapeutic response.
Orders that were unlikely to be carried out because of product characteristics, physical and mechanical factors, or the drug distribution and preparation processes of the hospital, etc. Assessment of the potential adverse outcome of each error was based on available patient and pharmacologic information regarding the risk for adverse events. Consistency and reproducibility of assigning an error severity classification to specific errors has been previously validated.
Errors related to dosage forms were defined as those in which there was an order for the inappropriate use of a specific dosage form, an order for the wrong dosage form errors of commission , or the failure to specify the correct dosage form when more than 1 dose form is commonly available error of omission.
A classification schema for dosage form errors was developed based on evaluation of errors prior to September 1, Table 1. Errors detected between September 1, and December 31, were evaluated in detail to provide a current assessment of medications involved, type of error, and the nature and severity of potential adverse effects had the order been carried out.
The total number of detected errors, and number of errors per admissions and number per 1, new medication orders detected increased annually over this period Fig. These errors were further evaluated for current determination of error characteristics, medications involved and potential for adverse outcomes. During these 16 months, errors were detected at a rate of 1. Number of errors per year A and frequency of prescribing errors per admissions and per 1, new orders B from through to Of the errors detected between September 1, and December 31, , the most common types of errors were: Table 1 lists the frequency of each type of error detected.
Table 2 lists the number of errors detected by specific medication involved and by medication class. Table 1 lists the number of errors rated as severe or serious for each type of dosage form prescribing error. Table 2 lists the number of severe or serious errors for each medication class and specific medication. Errors and deficiencies in prescribing have been reported to be the most common cause of preventable adverse drug events in hospitals.
However, the resulting availability of multiple dosage formulations, lack of caregiver appreciation for the uses and properties of various preparations, as well as high potential for adverse event if dose formulations are used improperly, create a significant risk of adverse patient events. The results of this study suggest that hospitalized patients are at significant and increasing risk for adverse events from prescribing errors involving medication dose formulations.
A large number of reports of significant adverse patient outcomes resulting from the inappropriate use of dosage formulations are available. A limitation of this study is the determination of the severity of an error based on the prediction of harm had the drug been administered as ordered.
Prediction of potential harm was based on consideration of pharmacologic, disease state, and individual patient characteristics. Despite these limitations, the classification system used has been found to be reliable and reproducible. For most of the errors reported, only mild to modest adverse events are likely, although serious events may occur in some patients.
An example of a fatal adverse outcome related to inappropriate administration of a dosage formulation combined with dispensing and administration error was reported by Smetzer and Cohen. However, the practices at the study hospital are similar to those in many U.
Thus, the errors reported in this study are likely to be representative of errors occurring in other teaching hospitals without prescriber computer order entry.
The underlying factors related to dosage form errors include: Given the many contributors to these errors, systems implemented to protect patients from potential risks must be multifaceted as well.
Formal education of health care providers and patients regarding the properties, availability, and proper use of the various medication dosage forms marketed is inadequate. Inclusion of basic information regarding the role of dose formulation issues in pharmacology and therapeutics courses for active and in-training prescribers, nurses, and pharmacists is necessary.
The nomenclature used for dosage forms is inconsistent and confusing. Terminology varies for individual drugs, within drug classes, or from one manufacturer to another. Adding suffixes to established names of medications e. This practice results in a lack of clear definition of different formulation properties, and the common problem of omitting the suffix when prescribing. Interestingly, some medications were more commonly found to be prescribed by their brand name, omitting the suffix bupropion, 13 of 13 occurrences; insulin, 32 of 35 occurrences; nifedipine, 37 of 39 occurrences; venlafaxine, 13 of 15 occurrences , whereas others were found to be more commonly prescribed as generic drugs without specifying the appropriate dosage form cyclosporine, 12 of 12 occurrences; isosorbide mononitrate, 26 of 30 occurrences; theophylline, 30 of 30 occurrences; verapamil, 22 of 27 occurrences.
It is likely that this reflects the frequency with which these drugs are referred to or thought of by brand or generic name, and the impact of marketing of specific agents. Compounding this problem is the failure of pharmaceutical firms to adequately address safety issues related to dose formulation in packaging and marketing of products.
For example, controlled-delivery formulations are often available in dose sizes that are simple multiples of the immediate-release form. This practice increases the likelihood that standard-release forms could be used to provide a controlled-release—sized dose e.
Considering the large number of agents now available for which suffixes denote special dose forms, any value this practice has in terms of convenience, simplification, and product identification, recognition, and differentiation, is minimal.
Use of suffixes in the naming of medications may now be causing so much confusion, and possibly patient harm, that the pharmaceutical industry and FDA should consider a moratorium on the practice until a full risk assessment can be performed.
At a minimum, to reduce risk, the simple practice of providing sustained-release forms in dose amounts that are not simple multiples of other dosage forms should be strongly considered. The use of unique names for special formulations i. Establishing an improved method of selecting and approving drug names and formulation designations may reduce the frequency of dose formulation—related errors and confusion.
Pharmaceutical firms and the U. Food and Drug Administration are urged to formally and systematically address dosage form issues in their drug naming and design processes. Improving the medication safety processes within health care generally and, where appropriate, those specifically related to dose formulation issues is necessary to the reduction of risk for adverse drug events from these types of errors.
Prescribing errors involving dosage formulations are common, and without appropriate safety processes such as pharmacist order review in place, present significant risk to patients. The increasing use and availability of unique dosage forms may account for the increasing number of errors detected over the 5-year study period. The finding of recurring errors of similar type supports the concept that prescribing errors are associated with identifiable factors, which provides opportunity for targeted improvements in the process of medication use.
Improvements in health care provider knowledge, dosage form safety design, improved nomenclature, and improvements in medication use system processes are necessary for safeguarding patients from errors involving medication dosage formulation.
The author wishes to acknowledge the effort of the Albany Medical Center Pharmacists in the detection of errors and collection of the data reported in this manuscript. National Center for Biotechnology Information , U.
Below is some guidance on what to do when such dosing errors occur, and how to avoid these errors in the future. This dose counts as valid. When errors of this nature occur, it is important to assess how the error happened and to implement strategies to ensure they will not be repeated. Administering larger-than-recommended doses of any vaccine does not negate the need for subsequent recommended doses.
Giving less than a full dose might result in inadequate protection. Revaccinate the patient with the appropriate dose according to recommendations specific to inactivated and live-virus vaccines. You may give the additional dose during the same visit if the error is discovered while the patient is still in the office. In such a case, if you administered the correct dosage to the child, even though it is the wrong product, consider the dose valid and do not repeat it.
Inform the patient, parent or guardian of the error and document it in the medical record. Resources that can help Here are examples of some strategies you can implement to prevent administering the wrong dose of vaccine: Sign up for email newsletter.
Standing Orders for Vaccination. The best way to understand how medication errors happen and how to avoid them is to consider their classification, which can be contextual, modal, or psychological.
Contextual classification deals with the specific time, place, medicines and people involved. Modal classification examines the ways in which errors occur for example, by omission, repetition or substitution.
Psychological classification is to be preferred, as it explains events rather than merely describing them. Its disadvantage is that it concentrates on human rather than systems sources of errors. The following psychological classification is based on the work of Reason on errors in general. There are four broad types of medication errors labelled 1—4 in Figure 2. A classification of types of medication errors based on psychological principles.
Rule-based errors using a bad rule or misapplying a good rule —for example, injecting diclofenac into the lateral thigh rather than the buttock. Proper rules and education help to avoid these types of error, as do computerized prescribing systems. Action-based errors called slips —for example, picking up a bottle containing diazepam from the pharmacy shelf when intending to take one containing diltiazem.
In the Australian study mentioned above most errors were due to slips in attention that occurred during routine prescribing, dispensing or drug administration. A subset of action-based errors is the technical error—for example, putting the wrong amount of potassium chloride into an infusion bottle. This type of error can be prevented by the use of checklists, fail-safe systems and computerized reminders.
Memory-based errors called lapses —for example, giving penicillin, knowing the patient to be allergic, but forgetting. These are hard to avoid; they can be intercepted by computerized prescribing systems and by cross-checking. For some examples of prescription errors see Table 1.
Examples of other types of medication errors under the same headings are given in reference 8. For example, working overtime with inadequate resources, poor support, and low job security all contributed to an increased risk of medication errors by nurses.
Improved education and improved working conditions, including better induction processes, should reduce the risk of errors that are due to these factors; a national prescription form would help. One difficulty in detecting errors is that those who make them fear disciplinary procedures and do not want to report them.
However, some systems for voluntarily reporting medical errors are of limited usefulness, because reports often lack details and there is incomplete reporting and underreporting.
Errors in prescribing can be divided into irrational prescribing, inappropriate prescribing, ineffective prescribing, underprescribing and overprescribing, and errors in writing the prescription. Failing to prescribe an anticoagulant for a patient in whom it is indicated underprescribing or prescribing one when it is not indicated overprescribing are different types of error from errors that are made when writing a prescription.
A rational approach can result in inappropriate prescribing, if it is based on missing or incorrect information. If, for example, one does not know that another prescriber has already prescribed paracetamol unsuccessfully for a headache, a prescription for paracetamol might be rational but inappropriate. Consider an example from my own practice. Her doctor reasoned as follows:.
Her doctor should have reasoned as follows:. This stresses the importance of understanding the relation between the pathophysiology of the problem and the mechanism of action of the drug see below. Ineffective prescribing is prescribing a drug that is not effective for the indication in general or for the specific patient; it is distinct from underprescribing see below.
One would expect ineffective prescribing to be minimized by the use of guidelines, but there is conflicting evidence; prescribing guidelines may be ineffective unless accompanied by education or financial incentives. Underprescribing is failure to prescribe a drug that is indicated and appropriate, or the use of too low a dose of an appropriate drug. The true extent of underprescribing is not known, but there is evidence of significant underprescribing of some effective treatments, such as angiotensin converting-enzyme inhibitors for patients with heart failure 36 and statins for hyperlipidaemia.
The sources of underprescribing include fear of adverse effects or interactions, failure to recognize the appropriateness of therapy, and doubts or ignorance about likely efficacy. Cost may play a part. In a study of the relation of underprescribing to polypharmacy in elderly patients, the probability of underprescribing increased significantly with the prescribed number of drugs. Overprescribing is prescribing a drug in too high a dosage too much, too often or for too long.
In some cases treatment is not necessary at all. For example, among hospital patients who were given a proton pump inhibitor treatment was indicated in only half. Overuse of antibiotics is well known and much discussed. A systematic review of 55 trials showed that no single strategy or combination of strategies was better than any other and none was highly effective, although the authors singled out active education of clinicians as a strategy to pursue.
In a Spanish study, those who overprescribed were more likely to be in rural practices, further from specialist centres, caring for children, lacking postgraduate education and in part-time or short-term work. All the factors that lead to medication errors in general contribute towards prescription errors. They include lack of knowledge, using the wrong drug name, dosage form, or abbreviation, and incorrect dosage calculations.
Prescribing Errors Involving Medication Dosage Forms
administering or taking the drug—wrong dose, wrong route, wrong . are four broad types of medication errors (labelled 1–4 in Figure 2) pharmacist) guidelines,medication error can be catagorized into 11 types. 1. prescribing error. writingdesk.pwon error. writingdesk.pwer dose errer. writingdesk.pworized drug error. Guide to help understand and demonstrate Dosage Calculations within the 1/2, 6/8 and 12/4, for example; the numerators for each of these fractions are 1, 6 and 12, The procedure for converting mixed numbers into improper fractions is.