Advertisement

Drug Safety

, Volume 29, Issue 11, pp 1011–1022 | Cite as

Clarification of Terminology in Medication Errors

Definitions and Classification
  • Robin E. Ferner
  • Jeffrey K. AronsonEmail author
Leading Article

Abstract

We have previously described and analysed some terms that are used in drug safety and have proposed definitions. Here we discuss and define terms that are used in the field of medication errors, particularly terms that are sometimes misunderstood or misused. We also discuss the classification of medication errors. A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Errors can be classified according to whether they are mistakes, slips, or lapses. Mistakes are errors in the planning of an action. They can be knowledge based or rule based. Slips and lapses are errors in carrying out an action — a slip through an erroneous performance and a lapse through an erroneous memory. Classification of medication errors is important because the probabilities of errors of different classes are different, as are the potential remedies.

Keywords

Medication Error Bosentan Chlorpropamide Wrong Dosage Epoxide Reductase 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

No sources of funding were used to assist in the preparation of this article. The authors have no conflicts of interest that are directly relevant to the content of this article.

References

  1. 1.
    Aronson JK, Ferner RE. Clarification of terminology in drug safety. Drug Saf 2005; 28: 851–70CrossRefPubMedGoogle Scholar
  2. 2.
    Buetow SA, Sibbald B, Cantrill JA, et al. Appropriateness in health care: application to prescribing. Soc Sci Med 1997; 45: 261–71CrossRefPubMedGoogle Scholar
  3. 3.
    Barker KN, Mikeal RL, Pearson RE, et al. Medication errors in nursing homes and small hospitals. Am J Hosp Pharm 1982; 39: 987–91PubMedGoogle Scholar
  4. 4.
    Barker K, Flynn E, Pepper G, et al. Medication errors observed in 36 health care facilities. Arch Intern Med 2002; 162: 1897–903CrossRefPubMedGoogle Scholar
  5. 5.
    Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Qual Saf Health Care 2003; 12: 343–7CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm 1993; 50: 305–14Google Scholar
  7. 7.
    Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events, and adverse drug reactions. Am J Health Syst Pharm 1998; 55: 165–6Google Scholar
  8. 8.
    Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285: 2114–20CrossRefPubMedGoogle Scholar
  9. 9.
    National Council focuses on coordinating error reduction efforts. USP Quality Review 1997; 57 [online]. Available from URL: http://www.usp.org/patientSafety/newsletters/qualityReview/qr571997-01-01a.html [Accessed 2006 Aug 20]Google Scholar
  10. 10.
    Dean B, Barber N, Schachter M. What is a prescribing error? Qual Health Care 2000; 9: 232–7CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Ferner RE, Aronson JK. Medication errors, worse than a crime. Lancet 2000; 355: 947–8CrossRefPubMedGoogle Scholar
  12. 12.
    Runciman W, Roughead E, Semple S, et al. Adverse drug events and medication errors in Australia. Int J Qual Health Care 2003; 15: 149–59CrossRefGoogle Scholar
  13. 13.
    Ito H, Yamazumi S. Common types of medication errors on long-term psychiatric care units. Int J Qual Health Care 2003; 15: 207–12CrossRefPubMedGoogle Scholar
  14. 14.
    Yu KH, Nation RL, Dooley MJ. Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough? Qual Saf Health Care 2005; 14: 358–63CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Kirwan B. A guide to practical human reliability assessment. London: Taylor & Francis, 1994Google Scholar
  16. 16.
    Barker KN, Mikeal RL, Pearson RE, et al. Medication errors in nursing homes and small hospitals. Am J Hosp Pharm 1982; 39: 987–91PubMedGoogle Scholar
  17. 17.
    Betz RP, Levy HB. An interdisciplinary method of classifying and monitoring medication errors. Am J Hosp Pharm 1985; 42: 1724–32PubMedGoogle Scholar
  18. 18.
    Tesh DE, Beeley L. Errors of drug prescribing. Br J Clin Pharmacol 1975; 2: 403–9CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Hynniman CE, Conrad WF, Urch WA, et al. A comparison of medication errors under the University of Kentucky unit dose system and traditional drug distribution systems in four hospitals. Am J Hosp Pharm 1970; 27: 802–14PubMedGoogle Scholar
  20. 20.
    Allan EL, Barker KN. Fundamentals of medication error research. Am J Hosp Pharm 1990; 47: 555–71PubMedGoogle Scholar
  21. 21.
    Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA 1990; 263: 2329–34CrossRefPubMedGoogle Scholar
  22. 22.
    Barber N. Should we consider non-compliance a medical error? Qual Saf Health Care 2002; 11: 81–4CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Hartwig SC, Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm 1991; 48: 2611–6PubMedGoogle Scholar
  24. 24.
    Neville RG, Robertson F, Livingstone S, et al. A classification of prescription errors. J R Coll Gen Pract 1989; 39: 110–2PubMedPubMedCentralGoogle Scholar
  25. 25.
    Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995; 274: 29–34CrossRefPubMedGoogle Scholar
  26. 26.
    Malpass A, Helps SC, Sexton EJ, et al. A classification for adverse drug events. J Qual Clin Pract 1999; 19: 23–6CrossRefPubMedGoogle Scholar
  27. 27.
    Ferner RE, Aronson JK. Errors in prescribing, preparing, and giving medicines: definition, classification, and prevention. In: Aronson JK, editor. Side effects of drugs, Annual 22. Amsterdam: Elsevier, 1999: xxiii–xxxviGoogle Scholar
  28. 28.
    Reason JT. Human error. New York: Cambridge University Press, 1990CrossRefGoogle Scholar
  29. 29.
    Norman DA. Categorization of action slips. Psychol Rev 1981; 88: 1–15CrossRefGoogle Scholar
  30. 30.
    Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 1993; 21: 506–19PubMedGoogle Scholar
  31. 31.
    Ferner RE, Langford NJ, Anton C, et al. Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. Br J Clin Pharmacol 2001; 52: 573–7CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Langford NJ, Landray M, Martin U, et al. Testing the practical aspects of therapeutics by objective structured clinical examination. J Clin Pharmacol Ther 2004; 29: 263–6CrossRefGoogle Scholar
  33. 33.
    Anton C, Nightingale PG, Adu D, et al. Improving prescribing using a rule based prescribing system. Qual Saf Health Care 2004; 13: 186–90CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Brown TC. Sodium bicarbonate treatment for tricyclic antidepressant arrhythmias in children. Med J Aust 1976; 2: 380–2PubMedGoogle Scholar
  35. 35.
    Ferner RE, Whittington RM. Coroner’s cases of death due to errors in prescribing or giving medicines or to adverse drug reactions: Birmingham 1986-1991. J R Soc Med 1994; 87: 145–8PubMedPubMedCentralGoogle Scholar
  36. 36.
    Mulchrone P. Guilty chemists; death baby pair made medicine 20 times too strong. The Mirror 2000 Mar 2: 18Google Scholar
  37. 37.
    Johnson CE, Vigoreaux JA. Compatibility of paraldehyde with plastic syringes and needle hubs. Am J Hosp Pharm 1984; 41: 306–8PubMedGoogle Scholar
  38. 38.
    DePrizio CJ. Liability and the buttocks. N Engl J Med 1969; 280: 1186CrossRefPubMedGoogle Scholar
  39. 39.
    Lee DC, Klachko MN. Falsely elevated lithium levels in plasma samples obtained in lithium containing tubes. J Toxicol Clin Toxicol 1996; 34: 467–9CrossRefPubMedGoogle Scholar
  40. 40.
    Pillans PI, Connor N. Tissue necrosis and necrotizing fasciitis after intramuscular administration of diclofenac. Ann Pharmacother 1995; 29: 264–6CrossRefPubMedGoogle Scholar
  41. 41.
    van der Linden PD, van der Lei J, Vlug AE, et al. Skin reactions to antibacterial agents in general practice. J Clin Epidemiol 1998; 51: 703–8CrossRefPubMedGoogle Scholar
  42. 42.
    Woods K. The prevention of intrathecal medication errors: a report to the Chief Medical Officer. London: Department of Health, 2001: 1–24Google Scholar
  43. 43.
    Lessons of malaria death. The Guardian 2000 Mar 3: 14Google Scholar
  44. 44.
    de Groen PC, Lubbe DF, Hirsch LJ, et al. Esophagitis associated with the use of alendronate. N Engl J Med 1996; 335: 1016–21CrossRefPubMedGoogle Scholar
  45. 45.
    Canet JJ, Garau J. Importance of dose and duration of betalactam therapy in nasopharyngeal colonization with resistant pneumococci. J Antimicrob Chemother 2002; 50: 39–43CrossRefPubMedGoogle Scholar
  46. 46.
    Hecker M, Aron D, Patel N, et al. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med 2003; 163: 972–8CrossRefPubMedGoogle Scholar
  47. 47.
    Ferner RE. Reducing medication errors. JAMA 2001; 286: 2091PubMedGoogle Scholar
  48. 48.
    Kosmidis HV, Bouhoutsou DO, Varvoutsi MC, et al. Vincristine overdose: experience with 3 patients. Pediatr Hematol Oncol 1991; 8: 171–8CrossRefPubMedGoogle Scholar
  49. 49.
    Collins DB. New Zealand’s medical manslaughter. Med Law 1992; 11: 221–8PubMedGoogle Scholar
  50. 50.
    Ludman P, Mason P, Joplin GF. Dangerous misuse of sulphonylureas. BMJ 1986; 293: 1287–8CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Sussman J, Brozena S, Skop N, et al. Accidental intravenous colchicine poisoning. Ther Drug Monit 2004; 26: 688–92CrossRefPubMedGoogle Scholar
  52. 52.
    Deardorff DL, Schmidt CN, Wiley RA. Effect of preparation techniques on mixing of additives in intravenous fluids in nonrigid containers. Hosp Pharm 1993; 28: 306–9PubMedGoogle Scholar
  53. 53.
    Williams RH. Potassium overdosage: a potential hazard of nonrigid parenteral fluid containers. BMJ 1973; 1: 714–5CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Drew D, Schumann D. Homogeneity of potassium chloride in small volume intravenous containers. Nurs Res 1986; 35: 325–9CrossRefPubMedGoogle Scholar
  55. 55.
    Beevers DG, Beevers M. Blood pressure measurement: worsening chaos. J Hum Hypertens 2000; 14: 415–6CrossRefPubMedGoogle Scholar
  56. 56.
    Abernathy CM, Dickinson TC. Massive air emboli from intravenous infusion pump: etiology and prevention. Am J Surg 1979; 137: 274–5CrossRefPubMedGoogle Scholar
  57. 57.
    Southern DA, Read MS. Overdosage of opiate from patient controlled analgesia device. BMJ 1994; 309: 1002CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Eckhoff C, Didomenico R, Shapiro N. Initiating warfarin therapy: 5mg versus 10mg. Ann Pharmacother 2004; 38: 2115–21CrossRefPubMedGoogle Scholar
  59. 59.
    Fennerty A, Dolben J, Thomas P, et al. Flexible induction dose regimen for warfarin and prediction of maintenance dose. BMJ 1984; 288: 1268–70CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Rieder MJ, Reiner AP, Gage BF, et al. Effect of VKORC1 haplotypes on transcriptional regulation and warfarin dose. N Engl J Med 2005; 352: 2285–93CrossRefPubMedGoogle Scholar
  61. 61.
    Aithal GP, Day CP, Kesteven PJ, et al. Association of polymorphisms in the cytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding complications. Lancet 1999; 353: 717–9CrossRefPubMedGoogle Scholar
  62. 62.
    Lindh J, Lundgren S, Holm L, et al. Several-fold increase in risk of overanticoagulation by CYP2C9 mutations. Clin Pharmacol Ther 2005; 78: 540–50CrossRefPubMedGoogle Scholar
  63. 63.
    Maxwell S, Walley T. Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow’s doctors. Br J Clin Pharmacol 2003; 55: 496–503CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005; 293: 1223–38CrossRefPubMedGoogle Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  1. 1.West Midlands Centre for Adverse Drug ReactionsCity HospitalBirminghamUK
  2. 2.Department of Clinical PharmacologyRadcliffe InfirmaryOxfordUK

Personalised recommendations