medication error: a systematic review and …

www.wjpps.com Vol 9, Issue 8, 2020.

1011

Komal et al. World Journal of Pharmacy and Pharmaceutical Sciences

MEDICATION ERROR: A SYSTEMATIC REVIEW AND

COMPARIOSON OF REPORTING SYSTEM IN USA, UK AND INDIA

Komal Baraiya* and Kashyap Thummar

Graduate School of Pharmacy, Gujarat Technological University, Ahmedabad – 382424,

Gujarat, India.

ABSTRACT

An important cause of patient morbidity and mortality, hence it can be

a confusing and underappreciated concept is known as medication

error. Both the national patient safety agency report 2004 (United

kingdom) and the Institute of Medicine report 2000(United State of

America) highlight that medical errors cause a large number of death

each year. As per the Institute of Medicine reports 44,000 to 98,000

deaths to occur yearly due to the medical error and Seven thousand

(7,000) deaths yearly were attributed to medication errors. Estimation

of 237 million medication errors occurs at some point in the

medication process in England per year. 5.2 million Medical error is

happening in India annually. Medication errors are extensively

characterized as any error in the prescribing, dispensing, or administration of a drug. But now

Recently medication error classified by mistakes, slips, and lapses based on the physiological

approach. A medication error may be caused by during manufacturing and drug delivery.

Medication error caused by different factors like lack of knowledge, insufficient staff and

resources, naming and labeling of medicine, poor communication with the patient, physician,

and pharmacist, etc. The reporting system important for the evaluation of the medication

error causes. United State of America and United Kingdom have a separate reporting system

for medication error but India still has no reporting system. It‟s reduced by new technology

like computerized physician operator entry (CPOE), double check system, avoid the use of

abbreviations, update the knowledge about the new drug and high-risk drug, etc.

KEYWORDS: Medication error, adverse drug event, patient safety, prescription error.

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 9, Issue 8, 1011-1030 Review Article ISSN 2278 – 4357

Article Received on

08 June 2020,

Revised on 28 June 2020,

Accepted on 18 July 2020

DOI: 10.20959/wjpps20208-16805

*Corresponding Author

Komal Baraiya

Graduate School of

Pharmacy, Gujarat

Technological University,

Ahmedabad – 382424

Gujarat, India.


1012


INTRODUCTION

Since this publication of the landmark Institute of Medicine (IOM) report To Err is Human,

which improves the enhanced focus on the safety of health care.[1]

The complexity of modern

pharmacotherapy lends itself by confusing patients and errors done by health care

professionals.[2]

Both the national patient safety agency report 2004 (UK) and the IOM report

2000(USA) highlight that medical errors cause a large number of death each year. According

to Institute of Medicine (IOM) report 44,000 to 98,000 deaths occur annually due to medical

errors, making medical errors the eighth leading cause of death in the United States. Seven

thousand (7,000) deaths yearly were recognized as medication errors.[3]

Estimation of 237

million medication errors occurs at some point in the medication process in England per

year.[4]

As per the investigation find out the 5.2 million Medical error is happening in India

annually. Due to lack of reporting system and absence of data registration system the exact

number of medication error difficult to find.[5]

The definition of medication error as „A failure

in the treatment process that leads to, or has the potential to lead to, harm to the patient‟.

Medication errors can happen at any stage of the medication use process and may or may not

lead to an ADE. Depending on the clinical setting, about one-third to one-half of ADEs are

related to medication errors.[3,6]

Medication error definition According to WHO and NCC

MERP "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. Such events may be related to professional practice,

healthcare products, procedures, and systems, including prescribing; order communication;

product labeling, packaging, and nomenclature; compounding; dispensing; distribution;

administration; education; monitoring; and use.",[7]

Figure 1: Relationship between ADEs, potential ADEs, and medication errors.[3]


1013


Classification

Medication error classified by a prescription error, administration error, transcription error,

monitoring error, dispensing error. But now Recently medication error classified by mistakes,

slips, and lapses based on the physiological approach. It Is also categorized by the National

Coordinating Council for Medication Errors Reporting and Prevention‟s (NCCMERP). The

NCCMERP taxonomy for medication errors defines four broad categories of errors: “No

error”, “error, no harm”, “error, harm” and “error, death”.[8]

Figure 2: Classification of medication errors based on psychological principles.[8]


1014


Table 1: Types and subtypes of medication errors with examples correlating with

medical-related side effects.[9]

Types of

medication error Sub-classifications Examples

Medical-related

side effects

Mistakes

Knowledge-based

Administering a type of antibiotic (i.e.

penicillin) without asking patient of his

allergy history

Anaphylaxis

Rule-

based

Applying a good

rule mistakenly

Injecting diclofenac at the deltoid muscle

instead of the gluteus muscle Hematoma

Applying a bad

rule

Continuously giving intramuscular

diclofenac 8 hourly to a patient in the out-

patient department; continuously giving a

loading dose of a medication

Hematoma

Skill-based errors

Action-based (slips)

Intending to write carbimazole on

prescription slip instead of carbamazepine;

writing a prescription beginning with carb,

followed by scribbles

side effects of

the drug which

was unintended to

be administered

Technical errors

Dispensing the wrong strength of medication

in the pediatric ward based on weight;

improper blood pressure measurement;

failing to turn off the intravenous set post-

infusion of medication

Under or

overtreatment; air

embolism

Memory-based (lapses)

Omitting the duration of warfarin for a

patient with atrial fibrillation in the

prescription; failure to inform the patient

regarding drug-food interactions in patients

on warfarin

Bleeding

tendencies; failure

of the efficacy of

warfarin

Statistics

Patient safety and treatment cost can be significantly affected by the medication error that

result in hazards for patient and their families. Medication errors can lead to adverse

outcomes such as increased mortality, increased duration of hospitalization, and increased

medical expenses.[5]

Both the national patient safety agency report 2004 (UK) and the IOM

report 2000(USA) highlight that medical errors cause a large number of death each year.

According to the report, a medication error is the most common type of error in health care.

According to IOM report prevalence of medication errors in the United States in which at

least 1.5 million Americans are injured and 7,000 deaths, every year by medication errors as

well as 44,000 to 98,000 deaths occur yearly due to medical errors, making medical errors the

eighth leading cause of death in the United States.[3]

As per the U.S. Pharmacopeia 8th

Annual MEDMARX® Report Specifies Look-Alike/Sound-Alike Drugs Lead to Thousands

of Medication Errors Nationwide.[10]

In England estimate the 237 million medication error

occur at some point in the medication process per year. The estimated NHS costs of definitely


1015


avoidable ADRs are £98.5 million per year, consuming 181,626 bed days, causing 712

deaths, and contributing to 1,708 deaths. 5.2 million Medical error is happening in India

annually.[4]

Figure 3: Medication error by type.[11]

Figure 4: Medication errors according to the class of drugs.[12]


1016


Figure 5: Risk percentage of individual drug.[11]


1017


Causes of medication errors

The factors that affect medication error are patient, health care professional, and medication

factors that are associated with the risk of a medication error.[13]

The Commonwealth Fund

International Health Policy survey compared factors associated with patient-reported

medication errors across seven countries. In 11% of patients experiencing a medication error,

risk factors included poor coordination of care, cost-related barriers to medical services or

medicines, multimorbidity and hospitalization Some of the key factors associated with

medication errors, including the Medication factors (eg, similar sounding names, low

therapeutic index), patient factors (eg, poor renal or hepatic function, impaired cognition,

polypharmacy), and health care professional factors (eg, use of abbreviations in prescriptions

and other communications, cognitive biases). Some Consequences faced by physicians after

medication errors that include loss of patient trust, civil actions, criminal charges, and

medical board discipline.[13,14]

A. Factors associated with health care professionals

Deficiency of therapeutic training

Insufficient drug knowledge and experience

Insufficient knowledge of the patient

Overworked or tired health care professionals

Physical and emotional health matters

Poor communication between health care professional and with patients

B. Factors associated with patients

Patient features (e.g., personality, literacy and language barriers)

The complexity of the clinical case, including multiple health conditions, polypharmacy,

and high-risk medications

C. Factors associated with the work environment

Workload and time pressures

Deficiency of standardized protocols and procedures

Insufficient resources

Issues with the physical work environment (e.g., lighting, temperature and ventilation)


1018


D. Factors associated with medicines

Naming of medicines

Labeling and packaging

E. Factors associated with tasks

Repetitive systems for ordering, processing, and authorization

Patient monitoring (dependent on practice, patient, other health care settings, prescriber)

F. Factors associated with computerized information systems

Tough processes for generating first prescriptions (e.g. drug pick lists, default dose

regimens, and missed alerts)

Tough processes for generating correct repeat prescriptions

Deficiency of accuracy of patient records

Poor design that allows for human error

Regulations and guidance of medication error

1. United states of america[15]

Guidance for Industry: Safety Considerations for Product Design to Minimize Medication

Errors

Guidance for Industry: Contents of a Complete Submission for the Evaluation of

Proprietary Names

Draft Guidance for Industry: Best Practices in Developing Proprietary Names for Drugs

Draft Guidance for Industry: Safety Considerations for Container Labels and Carton

Labeling Design to Minimize Medication Errors

Guidance for Industry and FDA Premarket and Design Control Reviewers - Medical

Device Use-Safety: Incorporating Human Factors Engineering into Risk Management

Draft Guidance for Industry and Food and Drug Administration Staff - Applying Human

Factors and Usability Engineering to Optimize Medical Device Design

PDUFA Pilot Project: Proprietary Name Review - Concept Paper

Medication Guides - Adding a Toll-Free Number for Reporting Adverse Events

Resources

Agency for Healthcare Research and Quality: Medical Errors and Patient Safety

Centers for Disease Control and Prevention: Medication Safety

Department of Veterans Affairs National Centre for Patient Safety


1019


Institute for Safe Medication Practices

National Patient Safety Foundation

To Err is Human: Building a Safer Health System (Institute of Medicine)

Preventing Medication Errors: Quality Chasm Series

National Coordinating Council for Medication Error Reporting and Prevention

Report medication error to FDA Med Watch

Guidance for Industry: Safety Considerations for Product Design to Minimize Medication

Errors Guidance for Industry

From our perspective: Working to prevent proprietary drug name confusion

Computerized Prescriber Order Entry Medication Safety (the )

Update on Phonetic and Orthographic Computer Analysis Tool

2. India[16]

National Patient Safety Implementation Framework (2018-2025)

3. UK[17,18]

Good Practice Guidance 10: Handling of medication errors, incidents and near misses in

Care Homes

GMC Good practice in prescribing and managing medicines and devices (2013)

Medication Errors

NICE guideline: Medicines optimization: the safe and Medicines optimization: the safe

and effective use of medicines to enable the best possible outcomes

GPhC Responding to complaints and concerns (2010)

NMC Standards for medicines management (2010)

CQC Fundamental Standards- Regulation 12

Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations

2010

Human Medicines Regulations 2012

NMC Standards for Medicines Management (2007)

NMC the Code, Nursing, and Midwifery Council (2015) and the Code. Professional

Standards of practice and behavior for nurses and midwives

NMC Standards and proficiency for nurse and midwife prescribers

Royal Pharmaceutical Society Medicines, Ethics, and Practice (2016)


1020


4. Current medication error reporting system

Reform of medicate on error reporting systems will help to prevent easily avoidable mistakes

and their often serious consequences. Pharmacists must learn to detect medication errors,

actual or potential, to understand their causes, and to propose system wide changes to reduce

the risks to patients.[19]

USA and UK having separate reporting system for the medication

error but in India have no reporting system for the medication error. In India Medication error

reporting including in the pharmacovigilance system.[20]

Table 2: Reporting system with country.[20]

Country Reporting system

USA

‒ United States Pharmacopeia

‒ ISMP

‒ MedWatch reports

‒ Manufacturer reports

UK ‒ National Reporting and Learning System (NRLS)

‒ National Patient Safety Agency (NPSA)

India No reporting system

Case study of medication error with prevention

1. Prescribing error

This is a story of a 73-year-old man with a history of cardiac arrhythmia who is presented in

the clinic for a routine follow-up visit. After when the evaluation was done by his physician,

the patient has received a handwritten prescription for Rythmol 150 mg, which he had been

taking for the previous 3 years. After filling this prescription from the clinical pharmacy and

he subsequently started to experience nausea, sweating, and an irregular heartbeat. After 2

weeks of symptoms, he called his physician for an appointment, noting that his Rythmol

tablets looked different than last time. When evaluated, the physician discovered that the

patient incorrectly received Synthroid (levothyroxine) 150 mcg from the pharmacy instead of

the prescribed Rythmol 150 mg.[21]

Problem: The prescription filled by the pharmacist was attributed because on the

prescription copy there was an error with an unclear handwriting

Prevention

Computerized Physician Order Entry (CPOE)

Computerized Decision Support Systems (CDSS)

Ensure knowledge before prescribing a drug

Ensure an accurate drug history which is taken

The drug name and patient details should be printed on the prescription


1021


Include all details of drug therapy i.e. name of drug, dose, directions, and duration of

therapy

Use of abbreviations should be avoided

Awareness of Look-alike and sound-alike products should be there

Implementing the use of tools for guiding medication prescribing

2. Dispensing error

A history of a 65-year-old female patient with an obstructive airway disease was seen by her

general practitioner, an oral penicillin product was prescribed and for seven days

prednisolone, 40 mg daily is also prescribed. The miss-selection was done by the community

pharmacist of a 28-day patient pack of propranolol 40 mg tablets instead of prednisolone 5

mg tablets and the pack was labeled with propranolol which a dispensing label with

instructions that to take eight tablets daily. The supplied was done by the same manufacturer

with both the prednisolone and propranolol tablet packs and the similarity of labeling and

packaging of the two products was the same in appearance. The first dose is taken by the

patient and soon afterward she had difficulty in breathing, she became hypotensive and lost

her consciousness. She rushed to the hospital where she can subsequently die.[21]

Problem: For the prednisolone tablets the pharmacist miss-selected the propranolol.

Prevention

Automated dispensing machine should be used

Every medicine should be cross-checked before dispensing it

A safe dispensing procedure should be ensured

Always use different brands or separating Lookalike and Sound alike products

At a safe and manageable level workload must be maintained

Be aware of high-risk drugs (HAM) e.g. Hypertonic Electrolytes (Potassium chloride,

Calcium chloride, Magnesium Sulphate), cytotoxic agents, IV Insulin

Good housekeeping practices can be introduced

Keep the storage area well organized

Different products should have a unique packaging and labeling system

3. Administration error

In the following traffic accident, a patient was admitted. He had sustained bilateral lower

limb fractures but was recovering well. The cardiac arrest followed with other symptoms and

also consistent with a large pulmonary embolus, the patient was resuscitated long enough and


1022


was enable him to be transferred to a critical care unit but afterward with a despite intensified

treatment he died shortly. In his drug chart, the prophylactic heparin injections were not

signed which are being administered to him on several occasions. What constitutes a

medicine administration error (MAE) varies from study to study that make comparisons

difficult? Some studies include time errors: for example, one hour earlier or later the

medicine was given for which it was prescribed for, while other studies ignore them.[21]

Problem: wrong administration of heparin in the wrong time

Prevention

Proper administration of the right medication at the right time

Medication Administration Record (MAR) properly maintain

Do a cross-check before giving any medicine

Check the patient‟s identity before administered any medicine

Provide educational session about good medication administration practices

Bar‐coded medication administration (BCMA) systems

4. Monitoring error

An emergency admission came to the hospital of a 42-year old male patient with lithium

toxicity. Unfortunately, his blood lithium levels were outdated. The last level that has been

recorded (5 months earlier) was inside the therapeutic range; hence his oral lithium

prescription was re-authorized. The two most recent outpatient appointments of his have been

canceled and his lithium levels were not regularly being monitored. At the time of reporting,

the patient was being ventilated.[21]

Problem: The lithium levels were not regularly being monitored

Prevention

Medication Administration Record (MAR) properly maintain

The patient‟s medication administration record should be regularly monitored

If you have the prescription, the drug and the patient in the same place so that they can be

checked against one another

Ensure that the medication is given at the correct time

Medication error prevention

The medication errors are diverse because of the root causes, multiple strategies are required

to prevent them. Campaigns such as the “5 Rights of Medication Administration “right drug,

right patient, right dose, right route, right time-have been used with limited success.[22]

The


1023


approaching system first of all requires improving medication safety and then reducing

medication errors. Strategies are employed which include using clinical pharmacists,

computer technology and educational programs, often within multifaceted interventions.

Most important interventions have been conducted in individual countries and may not be

generalizable to other countries where the health service structure is different, or where there

are different levels of availability of services (e.g. pharmacists) or technology (e.g.

computerized provider order entry). For over-the-counter medications, the FDA has also

worked to standardize labels to make them easier for patients to read.[14]

Medication reviews and reconciliation

The process of a patient‟s medicine evaluation to improve the health outcomes and mitigate

drug-related problems is known as Medication review. Primary care interventions are

designed to reduce medication-related adverse events that is found in the most successful

interventions which include a medication review which is conducted by a pharmacist or other

clinicians, or focused on multi-component interventions, by a primary care professional

medication is reviewed as one component. The formal process of establishing and

documenting a consistent, definitive list of medicines across transitions of care and then

rectifying any discrepancies is known as Medication reconciliation. Some medicines have

been tested for the reconciliation system. These new medication systems deal with changes,

deletions, and additions following hospital admissions. These systems reduced medication

discrepancies found in the systematic review, as well as potential and actual adverse drug

events.[14]

Medication reconciliation is a process that involves (1) verification of the patient‟s

medication history, (2) clarification that the medications are appropriate for the patient, and

(3) reconciliation of any discrepancies.[23]

Automated information systems

Computerized provider order entry (CPOE) with the decision support that may be effective

and if targeted at a limited number of potentially inappropriate medications which is designed

to reduce the alert burden by focusing on clinically-relevant warnings. To decrease the

frequency of medication error in the in-patient setting there is substantial evidence that

supports the use of CPOE. When an order was processed via CPOE the error occurrence was

decreased by 48%. However, there is additional research that is needed to link a decrease in

medication errors and patient harm.[14,24]

Bar‐coded medication administration (BCMA)


1024


systems require that the nurse who administers the medication at the bedside should scan the

patient's identification bracelet and the unit dose of the medication being administered.[25]

Education

The health care providers should be educated which is a key element to improve safety in

primary care. This holds medication errors which are reduced where education is often a part

of multicomponent interventions. In the educational interventions the improvement in the

prescription and dispensing of antibiotics that may impact on clinician behavior with

improved adherence to guidelines. The personal health records held by the patient often had a

positive effect on health outcomes, although there was the potential for a negative impact on

equity.[14]

Real-time education by pharmacists may also decrease errors. Pharmacist

participation as a full member of a health care team on hospital rounds also is reported to

decrease adverse drug events caused by prescribing errors.[26]

Multicomponent interventions

More than one intervention many studies were included. For improving the medication

practices evidence supports the use of multifaceted approaches. An inappropriate prescription

and the number of adverse drug events should be reduced. A study is to assess the progress in

improving the use of medicines reviewed by the empirical evidence and examined

ambulatory in primary care practices in 104 low- and middle-income countries. Complex

interventions, employing education, provide supervision, and community case management

strategies appeared are most effective.[14]

Example of medication error with prevention[22,27,28]

Unapproved abbreviations and illegible handwriting (for example, the U for units could be

confused for a zero; trailing zeros after a decimal could be mistaken for 20 rather than 2.0;

QD [every day] could be confused with QOD [every other day] or QID [4 times a day]).


1025


Table 3: List of abbreviations.

Abbreviations Intended Meaning Misinterpretation Suggested Practice

D/C Discharge or

discontinue

Premature discontinuation of drugs when

D/C (intended to mean discharge) was

interpreted as discontinued when

followed by a list of drugs

Use "discharge" and

"discontinue"

μ g microgram Mistaken for "mg" when handwritten Use "mcg"

q.d. or QD Every day Mistaken as q.i.d. (four times a day) Use "daily" or "every day"

q.o.d. or QOD Every other day Misinterpreted as q.d. (daily) or q.i.d.

(four times a day) Use "every other day"

Sub q Subcutaneous The "q" has been mistaken for "every" Use "subcutaneous"

U or u Unit Read as a zero (O) or a four (4), causing

a 10-fold overdose Use "unit"

Look-alike bottles should be placed in separate locations in a pharmacy and same strength

product labelling should be differentiate by giving the different color of strength (see figure.

Figure 6: Look-alike labels and labeling.


1026


Figure 7: Product Strength – Differentiation.

Figure 8: Look-alike & sound-alike names.

Similar sounding medications such as glyburide and glipizide can be labeled with “tall man

lettering” to decrease medication error.


1027


Table 4: Tall man lettering list.

Established Name Recommended Name Established Name Recommended Name

Acetohexamide

Acetazolamide

acetoHEXAMIDE

acetaZOLAMIDE

Medroxyprogesterone

Methylprednisolone

Methyltestosterone

MedroxyPROGESTERone

methylPREDNISolone

methylTESTOSTERone

Bupropion

Buspirone

buPROPion

busPIRone

Methylprednisolone

Methyltestosterone

methylPREDNISolone

methylTESTOSTERone

Chlorpromazine

Chlorpropamide

chlorproMAZINE

chlorproPAMIDE

Migalastat

Miglustat

migALAstat

migLUstat

Cisplatin

Carboplatin

CISplatin

CARBOplatin Mitoxantrone mitoXANTRONE

Clomiphene

Clomipramine

clomiPHENE

clomiPRAMINE

Nicardipine

Nifedipine

niCARdipine

NIFEdipine

Cyclosporine

Cycloserine

cycloSPORINE

cycloSERINE

Prednisone

Prednisolone

predniSONE

prednisoLONE

Daunorubicin

Doxorubicin

DAUNOrubicin

DOXOrubicin

Risperidone

Ropinirole

risperiDONE

rOPINIRole

Dimenhydrinate

Diphenhydramine

dimenhyDRINATE

diphenhydrAMINE

Sulfadiazine

Sulfisoxazole

sulfADIAZINE

sulfiSOXAZOLE

Dobutamine

Dopamine

DOBUTamine

DOPamine

Tolazamide

Tolbutamide

TOLAZamide

TOLBUTamide

Glipizide

Glyburide

glipiZIDE

glyBURIDE

Trazodone

Tramadol

traZODone

traMADol

Hydralazine

Hydromorphone

Hydroxyzine

hydrALAZINE

HYDROmorphone

hydrOXYzine

Vinblastine

Vincristine

vinBLAStine

vinCRIStine

Figure 9: Handwriting legibility.


1028


CONCLUSION

Medication errors are becoming a major threat to patients‟ safety. They lead to increased

morbidity and mortality rates, cost of treatment. Medication errors occur in all healthcare

systems with a combination of human factors and process issues. Eliminating all sources of

error is very difficult. Therefore identifying the causes of medication errors and developing

need-based strategies viz. medication error reporting system is important for identifying and

analyzing the causes of medication error. USA and UK have separate reporting system but in

India still have no reporting system for the medication error. Educational and incorporating

new information technologies in the existing healthcare system may help prevent medication

errors. All healthcare professionals have a responsibility in identifying contributing factors to

medication errors and to use that information to further reduce their occurrence. Minimizing

risks is feasible, and usually cost-effective. Care should be taken to ensure that the

medication is given safely and securely, by checking 3 things, MAR (Medication

Administration Record), doctors‟ orders and pharmacy label.

ACKNOWLEDGMENT

The Author and co-author, thanks to the graduate school of pharmacy for providing the

necessary facility to accomplish the work.

CONFLICT OF INTEREST

The authors confirm that this article's content has no conflicts of interest.

REFERENCES

1. Kaufman, D.W., Kelly, J.P., Rosenberg, L., Anderson, T.E., and Mitchell, A.A. Recent

patterns of medication use in the ambulatory adult population of the United States: the

Slone survey. Jama, 2002; 287(3): 337-44.

2. Makaryus, A.N. and Friedman, E.A. Patients' understanding of their treatment plans and

diagnosis at discharge. Mayo Clin Proc, 2005; 80(8): 991-4.

3. Williams, D. Medication errors. RCPE, 2007; 37(4): 343.

4. Rachel A Elliott1, E.C., Fiona Campbell2, Dina Jankovic3, Marrissa Martyn St James2,

Eva Kaltenthaler2, Ruth Wong2, Mark J Sculpher3, Rita Faria3 prevalence and economic

burden of medication errors in the nhs in england, 2018; 22.

5. Cheragi, M.A., Manoocheri, H., Mohammadnejad, E., and Ehsani, S.R. Types and causes

of medication errors from nurse's viewpoint. Iran J Nurs Midwifery Res, 2013; 18(3):

228-31.


1029


6. Bates, D.W. Medication Errors. Drug Safety, 1996; 15(5): 303-310.

7. National Coordinating Council for Medication Error Reporting and Prevention- Two

Decades of Coordinating Medication Safety Efforts, 2015.

8. Aronson, J.K. Medication errors: definitions and classification. Br J Clin Pharmacol,

2009; 67(6): 599-604.

9. Palasuberniam, P., Chin, S., Thangiah, V., and Dsouza, U.J.A. Medication Errors: A

Review of Classifications. BJMS, 2018: 11-18.

10. USP Report Cites Look-Alike/Sound-Alike Drugs-.

https://www.epocrates.com/marketing/company/news/PharmacyPractice_32008.pdf.

11. Polnariev, A. The Medication Error Prioritization System (MEPS): A Novel Tool in

Medication Safety. P T, 2014; 39(6): 443-7.

12. Mugada, V., Devineni, R.C., Pendyala, R.M., Vempati, D., and Kuchi, S. Categorization,

Appraisal, and Reporting of Medication Errors Ascertained in Medical Ward of Tertiary

Care Hospital. J. Appl. Pharm. Sci., 2018; 8(05): 109-114.

13. Lesar, T.S., Briceland, L., and Stein, D.S. Factors related to errors in medication

prescribing. Jama, 1997; 277(4): 312-7.

14. Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health

Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO, 2016.

15. Medication Errors Related to CDER-Regulated Drug Products.

https://www.fda.gov/drugs/drug-safety-and-availability/medication-errors-related-cder-

regulated-drug-products.

16. mohfw, National Patient Safety Implementation.

https://mohfw.gov.in/sites/default/files/national%20patient%20safety%20implimentation

_for%20web.pdf.

17. Medication Errors https://www.bcpft.nhs.uk/documents/policies/m/973-medication-

errors/file.

18. Management of Medication Errors Policy

https://www.lincolnshirecommunityhealthservices.nhs.uk/application/files/1615/2931/352

8/P_CIG_15_Management_of_Medication_Errors_Policy.pdf.

19. David, U. Medication error reporting systems: problems and solutions. New Medicine,

2001; 1(2): 61-5.

20. Terzibanjan, A.-R., Laaksonen, R., Weiss, M., Airaksinen, M., and Wuliji, T. Medication

error reporting systems–lessons learnt. FIP, 2007: 1-7.

http://www.epocrates.com/marketing/company/news/PharmacyPractice_32008.pdf

http://www.fda.gov/drugs/drug-safety-and-availability/medication-errors-related-cder-regulated-drug-products

http://www.fda.gov/drugs/drug-safety-and-availability/medication-errors-related-cder-regulated-drug-products

https://mohfw.gov.in/sites/default/files/national%20patient%20safety%20implimentation_for%20web.pdf

https://mohfw.gov.in/sites/default/files/national%20patient%20safety%20implimentation_for%20web.pdf

http://www.bcpft.nhs.uk/documents/policies/m/973-medication-errors/file

http://www.bcpft.nhs.uk/documents/policies/m/973-medication-errors/file

http://www.lincolnshirecommunityhealthservices.nhs.uk/application/files/1615/2931/3528/P_CIG_15_Management_of_Medication_Errors_Policy.pdf

http://www.lincolnshirecommunityhealthservices.nhs.uk/application/files/1615/2931/3528/P_CIG_15_Management_of_Medication_Errors_Policy.pdf


1030


21. Reporting and learning systems for medication errors: the role of pharmacovigilance

centres. http://apps.who.int/medicinedocs/documents/s21625en/s21625en.pdf.

22. ngoing Role of FDA in Medication Error Prevention

https://www.fda.gov/media/105396/download.

23. Manno, M.S. and Hayes, D.D. Best-practice interventions: how medication reconciliation

saves lives. Nursing, 2006; 36(3): 63-4.

24. Menendez, M.D., Alonso, J., Rancano, I., Corte, J.J., Herranz, V., and Vazquez, F. Impact

of computerized physician order entry on medication errors. Rev Calid Asist, 2012; 27(6):

334-40.

25. DeYoung, J.L., Vanderkooi, M.E., and Barletta, J.F. Effect of bar-code-assisted

medication administration on medication error rates in an adult medical intensive care

unit. Am J Health Syst Pharm, 2009; 66(12): 1110-5.

26. Leape, L.L., Cullen, D.J., Clapp, M.D., Burdick, E., Demonaco, H.J., Erickson, J.I., and

Bates, D.W. Pharmacist participation on physician rounds and adverse drug events in the

intensive care unit. Jama, 1999; 282(3): 267-70.

27. Ambwani, S., Misra, A.K., and Kumar, R. Medication Errors: Is it the Hidden Part of the

Submerged Iceberg in Our Health-care System? Int J Appl Basic Med Res, 2019; 9(3):

135-142.

28. USFDA, FDA List of Established Drug Names Recommended to Use Tall Man Lettering

(TML). https://www.fda.gov/drugs/medication-errors-related-cder-regulated-drug-

products/fda-name-differentiation-project.

http://apps.who.int/medicinedocs/documents/s21625en/s21625en.pdf

http://www.fda.gov/media/105396/download

http://www.fda.gov/drugs/medication-errors-related-cder-regulated-drug-products/fda-name-differentiation-project

http://www.fda.gov/drugs/medication-errors-related-cder-regulated-drug-products/fda-name-differentiation-project

medication error: a systematic review and …

Documents