ExCPT · Medication Safety and Quality Assurance · 6 min read
Types of Errors, Corrective Action and Reporting
- Differentiate between various types of medication errors, near misses, and their underlying system or human causes.
- Identify internal and external reporting pathways, safety cultures, and quality improvement frameworks used to investigate medication errors.
- Explain pharmacy technician responsibilities under pharmacist supervision regarding corrective strategies, risk-reduction strategies, and error prevention.
Understanding Medication Errors and Their Causes
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Sometimes an error is caught before it ever reaches the patient. This type of event is known as a near miss. Documenting near misses according to pharmacy policy is vital because it allows the pharmacist or safety team to review the incident and identify system vulnerabilities before actual patient harm occurs.
Errors generally stem from two primary sources: human error and system error. A human error is an unintentional slip, lapse, or mistake resulting from individual factors such as personal fatigue, unexpected distractions, or mathematical calculation errors. In contrast, a system error results from structural or organizational flaws within the workplace. Examples of system errors include inadequate lighting, a chaotic or poorly designed workflow, and improper drug storage practices.
Technology can also introduce risk into pharmacy operations. Software-related problems, such as computer malfunctions, corrupted data files, or unsafe system settings, can directly contribute to dispensing mistakes. Furthermore, modern pharmacy systems produce numerous electronic warnings. Alert fatigue occurs when frequent computer warnings, including low-value alerts, desensitize staff and increase the risk that critical, high-value alerts will be overlooked by the team.
| Error Type | Definition | Example Scenario |
|---|---|---|
| Omission Error | An ordered dose of medication is not administered or dispensed to the patient. | A scheduled maintenance dose is skipped or completely missing from a patient's filled prescription. |
| Wrong-Patient Error | A prescription is dispensed to, or labeled for, the incorrect individual. | Affixing patient A's prescription label onto a vial that is handed to patient B at the counter. |
| Wrong-Dose Error | The amount of active drug provided differs from the prescribed amount. | Dispensing a 20 mg tablet or an incorrect liquid concentration instead of the prescribed 10 mg strength. |
| Wrong-Route Error | A medication is administered by a pathway other than the one prescribed. | Administering an oral liquid medication through an intravenous line. |
| Wrong-Time Error | A medication is administered significantly outside its scheduled administration window. | Giving a time-sensitive medication hours after its prescribed administration timeframe. |
Common mistakes
- Assuming barcode scanning eliminates the need for final verification, forgetting that scanning is an assistive technical tool and only the pharmacist retains responsibility for final prescription verification.
- Using trailing zeros or omitting leading zeros when transcribing doses (for example, writing 5.0 mg instead of 5 mg, or .5 mg instead of 0.5 mg), which drastically increases the risk of a tenfold dosing error.
- Failing to report a near miss because no medication reached the patient, which misses a vital opportunity to identify system vulnerabilities.
- Attempting to counsel or resolve an issue when a patient calls to report an adverse reaction or wrong pill, rather than immediately transferring the call to the pharmacist.
Key points
- A medication error is a preventable event that may cause or lead to inappropriate medication use or patient harm; a near miss is an error caught before it reaches the patient and should be documented according to pharmacy policy.
- Errors arise from human errors (slips, lapses, fatigue) or system errors (poor lighting, flawed workflow, software problems, alert fatigue).
- Pharmacy technicians work under pharmacist supervision, immediately reporting suspected errors to the pharmacist and referring all clinical questions, adverse reaction reports, and patient counseling to the pharmacist.
- Documentation must be objective, factual, timely, and free of blame; external reporting can be completed through ISMP MERP, ISMP VERP, or FDA MedWatch.
- A Just Culture balances individual accountability with system evaluation, supported by tools like prospective Failure Mode and Effects Analysis (FMEA) and retrospective Root Cause Analysis (RCA) using the Five Whys.
- The Plan-Do-Check-Act (PDCA) continuous quality improvement framework allows pharmacy teams to test and standardize safety solutions.
- Key risk-reduction strategies include barcode scanning, Tall Man lettering, shelf separation, independent double-checks for high-alert medications, avoiding trailing zeros, and using leading zeros.
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