**3. Medication errors: terms and definitions**

Meurier et al. defined nursing errors as "every action, decision or omission of a nurse which was evaluated as incorrect by more experienced colleagues and had adverse effects on patients" [26]. In 1954, the American Hospital Association (AHA) defined for the first time medication error as "the administration of the wrong medication, medication dosage, diagnostic or therapeutic substance, to the wrong patient or at the wrong time, or the failure to administer these substances at a given time or according to the prescription or what is considered as acceptable practice" [27].

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines medication errors as: "any preventable event, which may cause or lead to inappropriate use of medications or to patient injury, while medication therapy is under the control of a health care professional, patient or user of health services. Such events may be associated with professional practices, healthcare products, procedures and systems including prescription, communication via instructions, product labeling, packaging and nomenclature, reformulation, dissolution, distribution, administration, education, monitoring and use" [28].

Choο et al. defined medication error as "any error during the medication administration, regardless of whether they have consequences or not" [29]. According to an ethnographic study in 2003 regarding the impact and the significance of intravenous medication errors, intravenous medication errors are defined as: "a divergence between the preparation and administration of an intravenous medication and the medical prescription, the hospital strategy regarding intravenous administrations and the instructions of the manufacturer" [30].

**4. Classifications of medication errors**

of administration) [33].

Gandhi et al. [32].

**i.** Errors in preparation

• Errors in copying medical instructions

• Incorrect content of the reconstituted drug

• Incorrect dosage due to miscalculations

• Wrong method of preparation and drug dissolution

• Incorrect selection of medication due to similar packaging

In 1960, Safren and Chapanis published the first study that documents the type of medication errors and classifies them into seven categories (wrong patient, wrong time, wrong dosage, omission of a dosage, administration of an extra dosage, wrong medicine, and wrong route

**Figure 1.** Relationship among medication errors, adverse drug events, and potential adverse drug events. Source:

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Medication errors could be classified into two major categories: the ones that occur prior to medication administration, during the preparation, and upon medication administration [30].

Medication preparation for the purpose of administration is a process that involves all these actions performed by nurses in order to reach the medication to patients ready for use. Some of the nursing medication errors upon preparation for hospitalization are [30, 34]:

The definitions of severity level for adverse drug events (ADEs) are presented in **Table 2** [31]. The relationship among medication errors, adverse drug events, and potential adverse drug events is illustrated in **Figure 1** [32].


**Table 2.** Definition of severity level for adverse drug events (ADEs).

**Figure 1.** Relationship among medication errors, adverse drug events, and potential adverse drug events. Source: Gandhi et al. [32].

#### **4. Classifications of medication errors**

In 1960, Safren and Chapanis published the first study that documents the type of medication errors and classifies them into seven categories (wrong patient, wrong time, wrong dosage, omission of a dosage, administration of an extra dosage, wrong medicine, and wrong route of administration) [33].

Medication errors could be classified into two major categories: the ones that occur prior to medication administration, during the preparation, and upon medication administration [30].

**i.** Errors in preparation

**3. Medication errors: terms and definitions**

considered as acceptable practice" [27].

80 Vignettes in Patient Safety - Volume 4

events is illustrated in **Figure 1** [32].

anaphylaxis

propose organ system dysfunction

fever, or symptomatic hypoglycemia

**Table 2.** Definition of severity level for adverse drug events (ADEs).

Significant ADE

Serious ADE

Lifethreatening ADE

Meurier et al. defined nursing errors as "every action, decision or omission of a nurse which was evaluated as incorrect by more experienced colleagues and had adverse effects on patients" [26]. In 1954, the American Hospital Association (AHA) defined for the first time medication error as "the administration of the wrong medication, medication dosage, diagnostic or therapeutic substance, to the wrong patient or at the wrong time, or the failure to administer these substances at a given time or according to the prescription or what is

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines medication errors as: "any preventable event, which may cause or lead to inappropriate use of medications or to patient injury, while medication therapy is under the control of a health care professional, patient or user of health services. Such events may be associated with professional practices, healthcare products, procedures and systems including prescription, communication via instructions, product labeling, packaging and nomenclature, reformulation, dissolution, distribution, administration, education, monitoring and use" [28]. Choο et al. defined medication error as "any error during the medication administration, regardless of whether they have consequences or not" [29]. According to an ethnographic study in 2003 regarding the impact and the significance of intravenous medication errors, intravenous medication errors are defined as: "a divergence between the preparation and administration of an intravenous medication and the medical prescription, the hospital strategy regarding intravenous administrations and the instructions of the manufacturer" [30].

The definitions of severity level for adverse drug events (ADEs) are presented in **Table 2** [31]. The relationship among medication errors, adverse drug events, and potential adverse drug

muscle cramps, inability to sleep, headaches, and pedal edema

to the point that a crucial physiologic function is at risk of failure

Happens if the event brings about symptoms that while substance to the patient creates little or no threat to the patient's life function. These ADEs could contain aggrandized or depressed laboratory test levels Examples of physical symptoms are categorized as sensation, physical tiredness, inability to defecate,

Happens if the event brings about persistent alteration of life function. Moreover serious ADEs could contain aggrandized or depressed lab values that require medical intervention, exceptionally if they

Happens if the event brings about symptoms or alterations that if not treated would put the patient at risk of death Life-threatening ADEs categorize laboratory values that are either aggrandized or depressed

Examples of physical symptoms; patient transferred to ICU due to respiratory failure, cardiac arrest, and

Examples of physical symptoms are categorized as a two-unit gastrointestinal bleed, a symptom requiring hospitalization, an altered mental status/excessive sedation, allergic reaction-shaking chills/ Medication preparation for the purpose of administration is a process that involves all these actions performed by nurses in order to reach the medication to patients ready for use. Some of the nursing medication errors upon preparation for hospitalization are [30, 34]:


**ii.** Errors in administration

Some of the most common errors in medication administration involve [30, 34]:

tool is objective, is uncomplicated to use, and defines clearly the four parameters, which are related to the severity of medication errors. These parameters are associated with the type of errors (i.e., wrong time, route, date, dosage, preparation, rate of administration, extra dosage, omission of a dosage), the route of administration (i.e., intravenous, intramuscular, oral, etc.), the classification of drugs according to a particular list that includes drugs with serious side effects in case of an error (i.e., heparin, digoxin, potassium), and the time between the medication error and the identification thereof. The last parameter constitutes an important role regarding patient's outcome, since it determines early or belated initiation of interventions that will prevent or reverse adverse consequences. Moreover, the abovementioned parameters are further categorized and rated each time depending on the situation. Finally, the total score depends on whether the patient has stated any allergies to a certain medication. This tool is particularly easy to use; it is designed to be accurate and reliable, and it has been used by the center in order to evaluate the severity of errors on the one hand and to determine further interventions by nursing stuff on the other. According to these data, classification and evaluation of medication errors depending on their severity may constitute an important tool for the improvement of processes in order to make medication administration as safe as

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Safren and Chapanis were the first to classify the causes of medication errors into 10 categories (not following any audit process, illegible medical instructions, errors in copying instructions, errors in classifying instructions, errors in calculating the dosage, improvisations, wrong medication labels, patient assignment to two nurses at the same time, poor oral communication, and more). Other criteria for the documentation involve the status of the person that made the mistake (student or worker), the nursing department where the error

Wakefield et al. classified the causes of medication errors into five categories this time [37]. The first category refers to the causes associated with the system (regular interruptions of nurses upon administering the medications, regular changes of nurses, simultaneous administration of medication for all the patients, poor authentication of patient's identity). The second category refers to the causes associated with the healthcare professional (failure to transpose instructions into the medication cards, poor communication between nurses regarding medication dosages that have not been administered, errors in copying instructions, noncompliance with the medication administration processes). This category also includes poor compliance of the healthcare professional with hospital policies and procedures, fragmentary

Other categories refer to causes related to doctors (illegible, unclear instructions, frequent changes of the instructions), pharmacies (imprecise medication dosage and administration or wrong dosages), and the adequate knowledge of the staff (inadequate knowledge

occurred, the time of day, and the severity of the patient's condition [33].

personal experiences of the nurses [38], and memory lapses [39].

possible [36].

**6. Etiology of medication errors**


The NCC MERP created an algorithm in order to classify medication errors into nine categories, based on the extent of the damage they may cause to the patient [35]:

	- **ix.** Permanent disability of the patient
	- **x.** Intervention required in order to keep the patient alive
	- **xi.** Death of the patient

#### **5. Assessment of medication errors**

According to the literature, one of the main characteristics of medication errors is their severity. In 1986, the El Dorado Medical Centre in Tucson, Arizona, developed a tool for the evaluation of medication errors, the so-called El Dorado Medication Error Tool (EDMET). This tool is objective, is uncomplicated to use, and defines clearly the four parameters, which are related to the severity of medication errors. These parameters are associated with the type of errors (i.e., wrong time, route, date, dosage, preparation, rate of administration, extra dosage, omission of a dosage), the route of administration (i.e., intravenous, intramuscular, oral, etc.), the classification of drugs according to a particular list that includes drugs with serious side effects in case of an error (i.e., heparin, digoxin, potassium), and the time between the medication error and the identification thereof. The last parameter constitutes an important role regarding patient's outcome, since it determines early or belated initiation of interventions that will prevent or reverse adverse consequences. Moreover, the abovementioned parameters are further categorized and rated each time depending on the situation. Finally, the total score depends on whether the patient has stated any allergies to a certain medication. This tool is particularly easy to use; it is designed to be accurate and reliable, and it has been used by the center in order to evaluate the severity of errors on the one hand and to determine further interventions by nursing stuff on the other. According to these data, classification and evaluation of medication errors depending on their severity may constitute an important tool for the improvement of processes in order to make medication administration as safe as possible [36].

#### **6. Etiology of medication errors**

**ii.** Errors in administration

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• Incorrect rate of administration

• Incorrect time of administration

• No medication administration

• Incorrect method of administration

• Repeated medication administration

Some of the most common errors in medication administration involve [30, 34]:

• Administering the wrong medication to the wrong patient

• Medication administration without medical prescription

**iii.** Conditions and events that may lead to an "error"

order to ensure that it did not cause any damage

**ix.** Permanent disability of the patient

**5. Assessment of medication errors**

**xi.** Death of the patient

• Interruption of medication administration whereas it should be continued • Continue medication administration against doctor's order to interrupt it

ries, based on the extent of the damage they may cause to the patient [35]:

**iv.** An error that finally did not cause any damage to the patient

**vii.** A temporary damage to the patient that requires intervention

**x.** Intervention required in order to keep the patient alive

**v.** An error that occurred to a patient but did not cause any damage

The NCC MERP created an algorithm in order to classify medication errors into nine catego-

**vi.** An error that occurred to a patient but required further monitoring or intervention in

**viii.** A temporary damage to the patient that requires initial or extended hospitalization

According to the literature, one of the main characteristics of medication errors is their severity. In 1986, the El Dorado Medical Centre in Tucson, Arizona, developed a tool for the evaluation of medication errors, the so-called El Dorado Medication Error Tool (EDMET). This

• Incorrect route of medication administration

Safren and Chapanis were the first to classify the causes of medication errors into 10 categories (not following any audit process, illegible medical instructions, errors in copying instructions, errors in classifying instructions, errors in calculating the dosage, improvisations, wrong medication labels, patient assignment to two nurses at the same time, poor oral communication, and more). Other criteria for the documentation involve the status of the person that made the mistake (student or worker), the nursing department where the error occurred, the time of day, and the severity of the patient's condition [33].

Wakefield et al. classified the causes of medication errors into five categories this time [37]. The first category refers to the causes associated with the system (regular interruptions of nurses upon administering the medications, regular changes of nurses, simultaneous administration of medication for all the patients, poor authentication of patient's identity). The second category refers to the causes associated with the healthcare professional (failure to transpose instructions into the medication cards, poor communication between nurses regarding medication dosages that have not been administered, errors in copying instructions, noncompliance with the medication administration processes). This category also includes poor compliance of the healthcare professional with hospital policies and procedures, fragmentary personal experiences of the nurses [38], and memory lapses [39].

Other categories refer to causes related to doctors (illegible, unclear instructions, frequent changes of the instructions), pharmacies (imprecise medication dosage and administration or wrong dosages), and the adequate knowledge of the staff (inadequate knowledge regarding adverse reactions of medications, poor access to Manuals of Pharmacology). Apart from these five categories of errors, it is worth referring to the causes that have been mentioned by other authors including incorrect mathematical calculations; poor dosage adjustment, in order to prevent liver and kidney damages; inability to obtain a proper medical history that may also include possible allergies to medication preparations; and inability to prevent synergistic effects between two or more drugs and to further convey this information to health professionals [40, 41]. Part of medication errors is largely attributable to lack of relevant information regarding the new technologies, such as the function of medical drug delivery pumps [39].

14 of which (11.6%) were threatening for the life of patients and 2 (1.6%) of them were lethal, whereas 24 (11%) of the 222 errors which were reported were evaluated as potentially threat-

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The use of technology contributes to the improvement of the quality of the services provided and maximizes the protection and safety of patients against eventual errors and events throughout healthcare provision. Intranet installation as well as the use of personal computers in healthcare provision units contributes to the implementation of automated (computerized) systems for the writing of medical instructions, therefore eliminating errors attributable

It also minimizes errors that occur while copying instructions on medication cards and prevents questions and misinterpretations, since every prescription includes mandatory fields that must be completed, such as route and time of administration as well as the precise dosage. Using special software for pharmacology, nurses can also be informed about possible allergies or side effects from incompatible medications every time they check on a patient's medical record. The placement of barcodes on every medication as well as the placement of identification wristbands for every patient upon admission to the hospital may decrease errors associated with inappropriate administration of medications with similar packaging and the administration of the wrong medication to the wrong patient. Using a wireless device at the time of hospitalization, nurses are able to monitor the administration of the appropriate medication preparation

The use of "smart" infusion pumps for intravenous medication administration and more specifically for the administration of unsafe preparations, such as heparin or insulin, predetermines the infusion rate and provides security alarms. Such pumps have been used for several years in specialized departments, such as ICU. The rapid technological development contributed to further improvement of the existing pumps by customizing them and giving the healthcare professional the ability to enter information, such as possible allergic reactions,

Additionally, nurses should ensure the correctness of their actions not only during the preparation but also during the execution of hospitalization, thereby eliminating any external interference. Preparation of hospitalization is also advised as well as dissolution of intravenous preparations, at a separate, individual space and not in the room, where patients may pose various questions to the nurse. Moreover, patients' escorts should not be in the wards during hospitalization, so that it is quite and the nurses can concentrate on the administration of

Last but not least, the medication errors may also be prevented by simplifying nursing actions, by developing and establishing guidelines and protocols that will be followed systematically during the preparation and the administration of medications. Yet it is imperative to ensure the proper staffing of every health institution with nursing staff, in order to increase the ratio

to the correct patient in the appropriate dosage using the appropriate route [53].

for every patient or install a software with pharmacology data [54].

medications without anything distracting their attention [54].

of nurses to patients.

ening for the life of patients [51].

to illegible handwritings [52].

**8. Prevention of medication errors**

Other causes of medication errors are associated with working conditions at the sites where medical products are produced, i.e., lighting conditions, noise, packaging, and nomenclature for medical products, i.e., medications with similar names, distribution and storage processes, and processes and protocols specified in every agency [42–45].

The NCC MERP documented 10 basic factors that influence medication use process and are frequently associated with the causes of medication errors. These 10 factors involve information related to the medical history of the patient; medications; communication between healthcare professionals, in order to convey information regarding medications; nomenclature and packaging of medication preparations; storage, safekeeping, and standardization of medication; acquisition, use, and monitoring of medication devices; environmental factors; competence and education of the staff and the patient; and quality and risk management processes [46].
