Overview of Medication Errors

and Strategies for Prevention

Ginna Castro
4th Year Pharmacy Student at UAMS
 Objectives
1. Identify common types of medication errors.

2. Understand the causes of medication errors.

3. Learn strategies to reduce medication errors.

4. Apply error prevention tools to improve communication and reduce errors.

5. Understand the importance of reporting medication errors and taking corrective

actions.

6. Know the steps to take when a medication error occurs (documentation,

communication, patient safety protocols).

7. Discuss the consequences of medication errors, including the importance of

transparency.
What is a Medication Error?

Any healthcare decision that

causes an unintended
consequence.
Common Types of Medication Errors

Prescription Errors

Omission Errors 68%

Wrong Dose Errors
Other Types of Medication Errors

Wrong Dosage Form

Wrong Drug Preparation

Deteriorated Drug Error

(expired)
 What are Some Causes of Medication Errors?

Miscommunication Not following

procedures

Workload Fatigue
Sound Alike Look Alike Drugs (SALADs)
SALAD Drugs: Sound-Alike, Look-Alike Drugs

● Medications with similar names (Sound-Alike)

● Medications with similar appearances (Look-Alike)
● Can lead to medication errors due to confusion

These similarities can lead to medication errors.

Tall Man Lettering and other safety practices are used to help
distinguish them.

Example:
PredniSONE vs. PredniSOLONE.
HydrOXYzine vs HydrALAzine
 High Alert Medications
High-alert medications are drugs that can cause serious harm if not used
properly. These require extra care when handling, prescribing, and
administering.

Examples:

➢ Insulin – Regulates blood sugar; incorrect doses can cause

imbalances.
➢ Opioids (e.g., morphine, fentanyl) – Pain relievers; overdoses can
cause breathing problems.
➢ Heparin – Prevents blood clots; dosing errors can cause bleeding.
➢ Chemotherapy drugs (e.g., methotrexate) – Treats cancer; incorrect
doses can harm organs.
➢ Antiepileptics (e.g., levetiracetam) – Controls seizures; wrong doses
can increase seizures.
 Error Prevention Tools at ACH

01 02 03 04 05

ARCC STAR SBAR QVV 200%

Accountability
Ask || Request || Concern || Chain of Command.
A.R.C.C.
Example: You receive an order for amoxicillin. The system shows it should be in a specific slot in the carousel, but
when you go pull the medication, you find azithromycin instead. You notice this has happened multiple times.

Ask a question:

"Is this the right location for amoxicillin? The drawer has azithromycin, but the system shows it should be
amoxicillin."."

Request a change:

“Can we verify the system's medication placement and update it if necessary to ensure amoxicillin is in the
correct slot?"

Concern - voice a concern:

“I'm concerned that the system might not be accurately reflecting the correct medication location, which
could lead to errors”

Chain of command:

If this issue persists, let’s involve the supervisor to ensure the system is updated and the medication is in the
correct place.
 S.T.A.R.
Stop || Think || Act || Review

You’re in a hurry and grab both amoxicillin and acetaminophen bottles to prepare oral syringes for
two pediatric patients. You scan the amoxicillin label first but accidentally scan the acetaminophen
bottle. The system immediately alerts you: "Incorrect medication."

Stop:
You immediately stop when you see the alert.

Think:
You realize you scanned the wrong bottle. You need to double-check the medications to avoid
mixing them up.

Act:
You grab the correct medication, and scan the correct amoxicillin bottle, confirming the
medication is right.

Review:
You double-check the syringe and confirm both syringes are correctly prepared with the right
medications before proceeding.
 Q.V.V.
Qualify || Validate || Verify ||

You’re working in the pharmacy, and you’ve just received a missing medication message for a
5-year-old patient, Max, who’s being treated for an infection. The order is for Ampicillin.

Qualify the source: (Do I trust the source?)

You first check the source of the order. You confirm that the order is in the patient's profile via Epic

Validate the content: (Does this make sense to me?)

You look in the system & confirm the dispensing history within Epic and DoseEdge. You notice it was
dispensed within the last 30 min.

Verify your action: (Check it with an expert)

Next, you verify with other team members if the medication has been dispensed. You go into the unit,
and verify the medication has already made it into the unit.
 S.B.A.R.
Situation || Background || Assessment || Recommendation

Situation: (What is the problem, patient, or project?)

On 1/14/2025, TBI kits will be removed from CVICU, ED, and PICU. Hypertonic 3% sodium
chloride will be stored in colored containers in Pyxis machines with "High Alert" stickers.

Background: (What is important to know?)

The ISMP recommended storing hypertonic 3% sodium chloride in Pyxis machines for higher
security and removing it from non-ADC storage.

Assessment: (What is your assessment of the situation? )

TBI kits currently contain hypertonic 3% sodium chloride and levetiracetam. These
medications will now be available in Pyxis machines in these areas for urgent use, eliminating the
need for TBI kits.

Recommendation: (What action/plan needs to take place?)

On 1/14/2025, TBI kits will be removed, and the Emergency Support Kits policy will be updated.
Levetiracetam and hypertonic 3% sodium chloride will be on override in Pyxis machines with "High
Alert" stickers.
 200% Accountability
You’re filling a prescription for amoxicillin suspension for a pediatric
patient.

Your 100% accountability:

You verify the medication, dosage, and label, ensuring everything matches
the prescription and the expiration date is valid.

Pharmacist’s 100% accountability:

You ask the pharmacist to double-check your work, confirming the
accuracy of the prescription and medication.

200% accountability:
Both you and the pharmacist take full responsibility for ensuring the
medication is correct and safe before dispensing.
 Reporting Errors - Safety Tracker
Purpose: A system for all staff at Arkansas Children’s Hospital to report safety events
or incidents related to patient care.

Categories: The tracker is divided into several categories, including:

● Formula/Nutrition/Dietary
● Adverse Drug Reactions
● Airway Management
1 2
● Skin or Tissue Injuries
● ETC

Accessibility:
The Safety Data Tracker can be accessed directly from the hospital's main page,
making it easy for staff to report events quickly.
3 4
Goal:
To ensure a culture of safety by allowing staff to report issues, enabling the hospital
to track and address potential hazards or problems.

Process: Once reported, the data is reviewed and used to make improvements in
practices, procedures, and patient care.
If an incident has a significant impact on patient safety, it is also reported to the
Institute for Safe Medication Practices (ISMP) for further review and guidance.
Reporting Errors - Safety Tracker
 Safety Huddles
What are safety huddles?
● Short daily meetings to discuss safety and operational concerns
● Focus on identifying past issues and potential risks.

Purpose of safety huddles

● Improve situational awareness of critical safety concerns
● Ensure efficient communication between departments & leadership
● Assign responsibilities for resolution & follow up

Huddle script:
Lookback:
What quality/safety issues occurred in the last 24 hours?
Look ahead:
What quality safety issues could we anticipate in the next 24 hours?
Situational Awareness:
Are there any high risk or unique situations that could impact quality/safety of
our teams/patients/families?
Learning from excellence:
What has gone well or what learning from excellence can be shared?
 Some Statistics
➢ Each year, there are about 1.5 million medication errors in the United
States.
➢ In hospitals, over 400,000 patients die annually due to medication
errors.
➢ Medication errors cause higher healthcare costs due to ER visits, extra
drug & medical therapies, and resulting disabilities.
➢ It’s estimated that 2% of all written prescriptions contain some form
medication errors.
➢ Medication errors can lead to ADRs, increasing patient illness and
death.
○ Medication errors affect about 1.5 million people each year, leading
to $3.5 billion in extra medical costs.
Comments/Questions?
 Resources
PTCB Exam Study Guide 2025-2026: 4 Full-Length Practice Tests and Pharmacy
Technician Certification (PTCE) Prep: [8th Edition]
by Jeremy Downs

Arkansas Children's Hospital. (n.d.). Safety culture - Safety as a core value [PowerPoint
slides]. Arkansas Children's Hospital.