, Volume 65, Issue 13, pp 1735–1746 | Cite as

Medication Errors

Hospital Pharmacist Perspective
  • Henk-Jan GuchelaarEmail author
  • Hadewig B. B. Colen
  • Mathijs D. Kalmeijer
  • Patrick T. W. Hudson
  • Irene M. Teepe-Twiss
Current Opinion


In recent years medication error has justly received considerable attention, as it causes substantial mortality, morbidity and additional healthcare costs. Risk assessment models, adapted from commercial aviation and the oil and gas industries, are currently being developed for use in clinical pharmacy.

The hospital pharmacist is best placed to oversee the quality of the entire drug distribution chain, from prescribing, drug choice, dispensing and preparation to the administration of drugs, and can fulfil a vital role in improving medication safety. Most elements of the drug distribution chain can be optimised; however, because comparative intervention studies are scarce, there is little scientific evidence available demonstrating improvements in medication safety through such interventions.

Possible interventions aimed at reducing medication errors, such as developing methods for detection of patients with increased risk of adverse drug events, performing risk assessment in clinical pharmacy and optimising the drug distribution chain are discussed. Moreover, the specific role of the clinical pharmacist in improving medication safety is highlighted, both at an organisational level and in individual patient care.


Medication Error Clinical Pharmacist Clinical Decision Support System Medication Safety Computerise Physician Order Entry 
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.



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


  1. 1.
    Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Committee on quality of health care in America; Institute of Medicine. Washington, DC: National Academy Press, 1999Google Scholar
  2. 2.
    Department of Health. Building a safer NHS for patients: improving medication safety. London: The Stationery Office, 2001Google Scholar
  3. 3.
    Audit Commission. A spoonful of sugar: medicines management in NHS hospitals. London: Audit Commission Publications, 2001Google Scholar
  4. 4.
    Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324(6): 377–84PubMedCrossRefGoogle Scholar
  5. 5.
    Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324(6): 370–6PubMedCrossRefGoogle Scholar
  6. 6.
    Australian Council for Safety and Quality in Health Care. Improving medication safety: report of a medication safety workshop, July 2001 [online]. Available from URL: [Accessed 2005 Jun 13]
  7. 7.
    Chan M, Nicklason F, Vial JH. Adverse drug events as a cause of hospital admission in the elderly. Intern Med J 2001; 31(4): 199–205PubMedCrossRefGoogle Scholar
  8. 8.
    National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) [online]. Available from URL: [Accessed 2005 Jun 13]Google Scholar
  9. 9.
    Busse DK, Wright DJ. Classification and analysis of incidents in complex medical environments. Top Health Inf Manage 2000; 20(4): 1–11PubMedGoogle Scholar
  10. 10.
    Beijer HJ, de Blaey CJ. Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci 2002; 24(2): 46–54PubMedCrossRefGoogle Scholar
  11. 11.
    Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998; 279(15): 1200–5PubMedCrossRefGoogle Scholar
  12. 12.
    Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA 1997; 277(4): 301–6PubMedCrossRefGoogle Scholar
  13. 13.
    Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003; 348(25): 2526–34PubMedCrossRefGoogle Scholar
  14. 14.
    Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 1998; 5(3): 305–14PubMedCrossRefGoogle Scholar
  15. 15.
    Silverman JB, Stapinski CD, Huber C, et al. Computer-based system for preventing adverse drug events. Am J Health Syst Pharm 2004; 61(15): 1599–603PubMedGoogle Scholar
  16. 16.
    Kanjanarat P, Winterstein AG, Johns TE, et al. Nature of preventable adverse drug events in hospitals: a literature review. Am J Health Syst Pharm 2003; 60(17): 1750–9PubMedGoogle Scholar
  17. 17.
    Hudson PTW. Applying the lessons of high risk industries to health care. Qual Saf Health Care 2003; 12 Suppl. 1: i7–21PubMedCrossRefGoogle Scholar
  18. 18.
    Reason J. Human error: models and management. BMJ 2000; 320(7237): 768–70PubMedCrossRefGoogle Scholar
  19. 19.
    van der Graaf GC, Milne D, Primrose M. HSE cases: some lessons learned. Exploration and Production Newsletter. The Hague: Shell International, 1996Google Scholar
  20. 20.
    Hudson PTW, Guchelaar H-J. Risk assessment in clinical pharmacy. Pharm World Sci 2003; 25(3): 98–103PubMedCrossRefGoogle Scholar
  21. 21.
    Gawande A. Complications. New York: Metropolitan Books, Henry Holt and Company, 2002Google Scholar
  22. 22.
    Molmans BHE, Kalmeijer MD, Reitsma RB, et al. Invloed van een electronisch voorschrijfsysteem op medicatiegerelateerde foutmeldingen. Pharm Weekbl Ziekenhuisfarmacie 2004; 139(47): 1547–9Google Scholar
  23. 23.
    Denig P, Haaijer-Ruskamp FM. Therapeutic decision making of physicians. Pharm Weekbl Sci 1992; 14(1): 9–15PubMedCrossRefGoogle Scholar
  24. 24.
    Schumock GT, Walton SM, Park HY, et al. Factors that influence prescribing decisions. Ann Pharmacother 2004; 38(4): 557–62PubMedCrossRefGoogle Scholar
  25. 25.
    Studdert DM, Mello MM, Brennan TA. Financial conflicts of interest in physicians’ relationships with the pharmaceutical industry: self-regulation in the shadow of federal prosecution. N Engl J Med 2004; 351(18): 1891–900PubMedCrossRefGoogle Scholar
  26. 26.
    Silverman JB, Stapinski CD, Churchill WD, et al. Multifaceted approach to reducing preventable adverse drug events. Am J Health Syst Pharm 2003; 60: 582–6PubMedGoogle Scholar
  27. 27.
    Janknegt R, Steenhoek A. The System of Objectified Judgement Analysis (SOJA): a tool in rational drug selection for formulary inclusion. Drugs 1997; 53(4): 550–62PubMedCrossRefGoogle Scholar
  28. 28.
    Pedersen CA, Schneider PH, Santell JP. ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing — 2001. Am J Health Syst Pharm 2001; 58: 2251–66PubMedGoogle Scholar
  29. 29.
    Wade WE, Spruill WJ, Taylor AT, et al. The expanding role of pharmacy and therapeutics committees: the 1990s and beyond. Pharmacoeconomics 1996; 10(2): 123–8PubMedCrossRefGoogle Scholar
  30. 30.
    Weekes LM, Brooks C. Drug and therapeutics committees in Australia: expected and actual performance. Br J Clin Pharmacol 1996; 42(5): 551–7PubMedGoogle Scholar
  31. 31.
    Fijn R, Brouwers JRBJ, Knaap RJ, et al. Drug and therapeutics (D & T) committees in Dutch hospitals: a nation-wide survey of structure, activities, and drug selection procedures. Br J Clin Pharmacol 1999; 48(2): 239–46PubMedCrossRefGoogle Scholar
  32. 32.
    Fijn R, Lenderink AW, Egberts AC, et al. Assessment of indicator for hospital drug formulary non-adherence. Eur J Clin Pharmacol 2001; 57(9): 677–84PubMedCrossRefGoogle Scholar
  33. 33.
    Kweekel DM, le Cessie S, Guchelaar HJ, et al. Outcomes of an antimicrobial control program in a Dutch hospital. Am J Health Syst Pharm 2004; 61(16): 1702–6PubMedGoogle Scholar
  34. 34.
    Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280(15): 1311–6PubMedCrossRefGoogle Scholar
  35. 35.
    Guchelaar HJ, Kalmeijer MD. The potential role of computerisation and information technology in improving prescribing in hospitals. Pharm World Sci 2003; 25(3): 83–7PubMedCrossRefGoogle Scholar
  36. 36.
    Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med 2003; 163(12): 1409–16PubMedCrossRefGoogle Scholar
  37. 37.
    Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999; 6(4): 313–21PubMedCrossRefGoogle Scholar
  38. 38.
    Weingart SN, Toth M, Sands DZ, et al. Physicians’ decisions to override computerized drug alerts in primary care. Arch Intern Med 2003; 163(21): 2625–31PubMedCrossRefGoogle Scholar
  39. 39.
    Hsieh TC, Kuperman GJ, Jaggi T, et al. Characteristics and consequences of drug-allergy alert overrides in a computerized physician order entry system. J Am Med Inform Assoc 2004; 11(6): 482–91PubMedCrossRefGoogle Scholar
  40. 40.
    Oren E, Shaffer ER, Guglielmo BJ. Impact of emerging technologies on medication errors and adverse drug events. Am J Health Syst Pharm 2003; 60(14): 1447–58PubMedGoogle Scholar
  41. 41.
    Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293(10): 1197–203PubMedCrossRefGoogle Scholar
  42. 42.
    Kalmeijer MD, Holtzer W, van Dongen R, et al. Implementation of a computerized physician medication order entry system at the Academic Medical Centre in Amsterdam. Pharm World Sci 2003; 25(3): 88–93PubMedCrossRefGoogle Scholar
  43. 43.
    Colen HB, Neef C, Schuring RW. Identification and verification of critical performance dimensions: phase 1 of systematic process redesign of drug distribution. Pharm World Sci 2003; 25(3): 118–25PubMedCrossRefGoogle Scholar
  44. 44.
    Taxis K, Barber N. Causes of intravenous medication errors: an ethnographic study. Qual Saf Health Care 2003; 12(5): 343–7PubMedCrossRefGoogle Scholar
  45. 45.
    Poley MJ, Bouwmans CA, Hanff LM, et al. Efficiency of different systems for medication distribution in an academic children’s hospital in The Netherlands. Pharm World Sci 2004; 26(2): 83–9PubMedCrossRefGoogle Scholar
  46. 46.
    Lewis RF, editor. The impact of information technology on patient safety. Chicago (IL): Healthcare Information and Management Systems Society, 2002Google Scholar
  47. 47.
    Lenderink BW, Egberts TC. Closing the loop of the medication use process using electronic medication administration registration. Pharm World Sci 2004; 26(4): 185–90PubMedCrossRefGoogle Scholar
  48. 48.
    Leape LL, Cullen DJ, Dempsey Clapp M, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 281(3): 267–70CrossRefGoogle Scholar
  49. 49.
    Kucukarslan SN, Peters M, Mlynarek M, et al. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med 2003; 163: 2014–8PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2005

Authors and Affiliations

  • Henk-Jan Guchelaar
    • 1
    Email author
  • Hadewig B. B. Colen
    • 2
  • Mathijs D. Kalmeijer
    • 3
  • Patrick T. W. Hudson
    • 4
  • Irene M. Teepe-Twiss
    • 1
  1. 1.Department of Clinical Pharmacy and ToxicologyLeiden University Medical CenterLeidenThe Netherlands
  2. 2.Department of Clinical PharmacyMedical Spectrum TwenteEnschedeThe Netherlands
  3. 3.Department of Clinical PharmacyAcademic Medical CenterAmsterdamThe Netherlands
  4. 4.Department of Psychology, Center for Safety Science, Faculty of Social and Behavioural SciencesLeiden UniversityLeidenThe Netherlands

Personalised recommendations