What are the Three Most Common Causes of Medication Errors?

What are the Three Most Common Causes of Medication Errors

Medication errors are an error in the prescribing, preparation, dispensing, administering, monitoring or providing of advice on medications. According to the National Reporting and Learning Systems (MRLS) a “patient safety incident” is “any unintended or unexpected incident, which could have or did lead to harm for one or more patients…”  Errors of commission include giving the wrong medicine or wrong dose.  Errors of omission include forgetting a dose (omitting a dose) or a failure to monitor.   Adverse drug reactions are also considered medication errors.

As many as 70% of care home residents experience an error at some point.  Medication optimisations are recommended to mitigate these often multi-faceted, unrecognised and often under-reported instances.  According to a 2020 BMJ (British Medical Journal) study, there were more than 237 million medication errors in England alone.  42% of those were in care homes.  80% of the errors causing death are caused by gastrointestinal bleeds from NSAIDs, aspirin or the blood thinner, warfarin.

The three most common causes of medication errors in a care home environment are: 

Dosage error – Miscalculating a dose is particularly true with liquid medications.  Many elderly patients are unable to swallow pills and are given liquid forms of medication.  If a dosage strength is not recorded properly, it is possible another dose would inadvertently be given.  This can also be true for pills, but it is a bit easier to count pills than measuring liquid.

Incorrect medicine – if a care home resident or an individual is taking a couple or few medications that are similar in appearance, it is possible to dispense the incorrect medication or for the resident to mistakenly take the same pill twice, and/or the correct pills not at all.

Adverse drug reaction – many people with complex health issues take numerous over the counter medications in addition to their prescription medications.  It is very easy to purchase some medications at the grocery store or another chemist who does not have a record of medications you are on.  There are many kinds of adverse reactions between over the counter medications and prescription medications that staff, residents, family and all carers should be aware of.

The best way to avoid any confusion where complex health and multiple medications are involved is to ask your care home pharmacy about a dosette box service for your residents.  Pharmacy to My Door is your dosette box pharmacy in Kineton, Shipston on Stour and Moreton in Marsh.

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