How Can I Avoid Medication Errors?

How Can I Avoid Medication Errors?

Donald C. Plumb, PharmD

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How Can I Avoid Medication Errors?

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.—National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)


All of us make mistakes—often with little consequence. But mistakes involving medication use can have lasting effects that linger beyond a single patient outcome. Medication errors can occur at any point in the chain of drug activity—from point of manufacture to writing the orders to having the prescription filled to owner compliance.

More than 200,000 medication errors were documented in human medicine in 2002, with 3000+ resulting in patient harm. (Summary of Information submitted to MEDMARX 2002: The quest for quality; USP, accessed July 2008)

Statistics in human medicine over the past decade became so sobering that the FDA created resources devoted to medication safety, specifically the Division of Medication Errors and Technical Support. This organization focuses on rectifying and implementing strategies that effect changes in tracking medications and identifying/monitoring problem areas. Several other organizations—Institute for Safe Medication Practices (ISMP), NCC MERP, and United States Pharmacopeia (USP)—are also working to alleviate risks associated with medication errors in human medicine.

  • Evidence cited by the Institute of Medicine of the National Academies as far back as 2006 suggests that at least 1.5 million preventable adverse drug events (ADEs) occur each year in the United States (Aspden P, et al. Preventing Medication Errors, National Academy Press, 2006).
  • Today the true number is likely much higher.

In veterinary medicine, the scope of medication errors remains unknown, but two clinical reports truly reflected an error:

  • Case report of two kittens receiving azathioprine instead of azithromycin after the order was called into the pharmacy incorrectly (JAAHA 44[1]:25-41, 2008).
  • Case report of two dogs and a cat inadvertently receiving penicillin G procaine–penicillin G benzathine IV instead of propofol during induction of anesthesia (JAVMA 238[4]:507-510, 2011).

Adverse drug events are not classified as medication errors, but a medication error can result in an adverse drug event.

To prevent statistics similar to the rising error rates in human medicine, the FDA CVM initiated the Division of Surveillance to report medication errors in animals and apply lessons learned from human medicine.


The following solutions may sound easy, but success involves dedicated staff and willingness to recognize, follow, and adhere to key safety measures.


Develop a culture & system to track medication errors

Fix the system, not the person:

  • Determine which medication errors occur most often in your practice
  • Use nonjudgmental manner when reviewing errors
  • Admonish employees only if they do NOT report errors
  • Double-check processes, especially for high-alert drugs

Determine in advance what to do when an error is discovered

No harm, no foul?

  • If there is potential for harm, alert the pet owner, apologize, and assure that safety measures are in place
    • Contact insurance carrier if patient harm is a concern


Write clear prescription orders

Consider using a computerized prescription system:

  • If orders are handwritten, write legibly
  • Cite drug strength, concentration, dosage
  • Avoid unclear abbreviations and nomenclature
    • Write out orders so everyone understands
      • Example: Give 1 tablet by mouth (oral) 2 times a day, once in morning and once at bedtime
    • Write out once a day, every other day, 3 times a day, etc
      • SID and/or s.i.d. is NOT an acceptable abbreviation on prescriptions,as neither is recognized by most pharmacists
    • Write out subcutaneous, oral (by mouth), intravenous, intramuscular
    • Write out microgram, gram, units
      • Okay to abbreviate mg, mL, kg, mEq
    • Do not use trailing zeros and naked decimals
      • 10 mg, but not 10.0 mg 
      • 0.5 mg, but not .5 mg
    • Write out “both eyes,” “left eye,” "right eye" instead of OU, OS, OD
  • Specify species, weight, age
  • Avoid phoning in prescriptions
Misinterpretation of a drug’s name can result in giving the wrong drug to a patient. Here are some of the worse offenders commonly mistaken for each other.
Alkeran | Leukeran
Allegra | Viagra
amlodipine | amiloride
benazepril | Benadryl
Brevibloc | Brevital
buspirone | bupropion
carboplatin | cisplatin   
carvedilol | captopril
clonidine | clonazepam
glyburide | glipizide | glimepiride
hydroxyzine | hydralazine
Keflex | Keppra
paroxetine | piroxicam
phenobarbital | pentobarbital
sertraline | cetirizine   
sulfadiazine | sulfasalazine
tramadol | trazodone
vincristine | vinblastine

Set up in-house pharmacy

Dedicate a secure area with no traffic and minimal distractions:

  • Set up double-check system
    • Second person verifies drug being ordered
  • Properly dilute IV drugs
  • Do not keep expired drugs in inventory
  • Beware of drug counterfeits
  • Store all drugs properly
  • Invest in labels and containers that meet (if not exceed) human pharmacy standards
    • Do not use envelopes for dispensing drugs
    • Use child-resistant packaging
    • Affix appropriate ancillary labeling (shake well, keep refrigerated)
    • Affix red stickers to bottles of high-alert drugs (insulin, critical care drugs, injectable anesthetics, opioids, neuro–muscular blockers, etc)
  • Label all inpatient medications (including syringes) at a minimum with patient name, drug name & concentration, dose amount & frequency, and date/time to use


Know your clients

Devote as much time ensuring that owners follow prescription orders as you do making a diagnosis or choosing a treatment plan:

  • Give clients information needed to use drugs correctly
  • Make sure clients truly understand label instructions
    • Verbally review key points and hand out client information sheets
  • Encourage clients to call if they have questions
  • On rechecks, ask clients to bring the pill bottle so staff can review how the pet receives its medication
  • Do not assume that therapy is not working because the dose needs to be adjusted or the drug needs to be changed
    • Do assume that clients need more time understanding how the drug works and what results to expect

Portions of this column have been adapted from “Medication Errors: Strategies to Reduce Them in Your Practice” by Donald C. Plumb, PharmD; presented at Wisconsin Veterinary Medical Association Annual Convention, 2012.

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