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Published in: Drug Safety 11/2006

01-11-2006 | Leading Article

Clarification of Terminology in Medication Errors

Definitions and Classification

Authors: Robin E. Ferner, Dr Jeffrey K. Aronson

Published in: Drug Safety | Issue 11/2006

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Abstract

We have previously described and analysed some terms that are used in drug safety and have proposed definitions. Here we discuss and define terms that are used in the field of medication errors, particularly terms that are sometimes misunderstood or misused. We also discuss the classification of medication errors. A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Errors can be classified according to whether they are mistakes, slips, or lapses. Mistakes are errors in the planning of an action. They can be knowledge based or rule based. Slips and lapses are errors in carrying out an action — a slip through an erroneous performance and a lapse through an erroneous memory. Classification of medication errors is important because the probabilities of errors of different classes are different, as are the potential remedies.
Literature
1.
2.
go back to reference Buetow SA, Sibbald B, Cantrill JA, et al. Appropriateness in health care: application to prescribing. Soc Sci Med 1997; 45: 261–71CrossRefPubMed Buetow SA, Sibbald B, Cantrill JA, et al. Appropriateness in health care: application to prescribing. Soc Sci Med 1997; 45: 261–71CrossRefPubMed
3.
go back to reference Barker KN, Mikeal RL, Pearson RE, et al. Medication errors in nursing homes and small hospitals. Am J Hosp Pharm 1982; 39: 987–91PubMed Barker KN, Mikeal RL, Pearson RE, et al. Medication errors in nursing homes and small hospitals. Am J Hosp Pharm 1982; 39: 987–91PubMed
4.
go back to reference Barker K, Flynn E, Pepper G, et al. Medication errors observed in 36 health care facilities. Arch Intern Med 2002; 162: 1897–903CrossRefPubMed Barker K, Flynn E, Pepper G, et al. Medication errors observed in 36 health care facilities. Arch Intern Med 2002; 162: 1897–903CrossRefPubMed
6.
go back to reference ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm 1993; 50: 305–14 ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm 1993; 50: 305–14
7.
go back to reference Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events, and adverse drug reactions. Am J Health Syst Pharm 1998; 55: 165–6 Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events, and adverse drug reactions. Am J Health Syst Pharm 1998; 55: 165–6
8.
go back to reference Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285: 2114–20CrossRefPubMed Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285: 2114–20CrossRefPubMed
9.
go back to reference National Council focuses on coordinating error reduction efforts. USP Quality Review 1997; 57 [online]. Available from URL: http://www.usp.org/patientSafety/newsletters/qualityReview/qr571997-01-01a.html [Accessed 2006 Aug 20] National Council focuses on coordinating error reduction efforts. USP Quality Review 1997; 57 [online]. Available from URL: http://​www.​usp.​org/​patientSafety/​newsletters/​qualityReview/​qr571997-01-01a.​html [Accessed 2006 Aug 20]
11.
12.
go back to reference Runciman W, Roughead E, Semple S, et al. Adverse drug events and medication errors in Australia. Int J Qual Health Care 2003; 15: 149–59CrossRef Runciman W, Roughead E, Semple S, et al. Adverse drug events and medication errors in Australia. Int J Qual Health Care 2003; 15: 149–59CrossRef
13.
go back to reference Ito H, Yamazumi S. Common types of medication errors on long-term psychiatric care units. Int J Qual Health Care 2003; 15: 207–12CrossRefPubMed Ito H, Yamazumi S. Common types of medication errors on long-term psychiatric care units. Int J Qual Health Care 2003; 15: 207–12CrossRefPubMed
14.
go back to reference Yu KH, Nation RL, Dooley MJ. Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough? Qual Saf Health Care 2005; 14: 358–63CrossRefPubMedPubMedCentral Yu KH, Nation RL, Dooley MJ. Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough? Qual Saf Health Care 2005; 14: 358–63CrossRefPubMedPubMedCentral
15.
go back to reference Kirwan B. A guide to practical human reliability assessment. London: Taylor & Francis, 1994 Kirwan B. A guide to practical human reliability assessment. London: Taylor & Francis, 1994
16.
go back to reference Barker KN, Mikeal RL, Pearson RE, et al. Medication errors in nursing homes and small hospitals. Am J Hosp Pharm 1982; 39: 987–91PubMed Barker KN, Mikeal RL, Pearson RE, et al. Medication errors in nursing homes and small hospitals. Am J Hosp Pharm 1982; 39: 987–91PubMed
17.
go back to reference Betz RP, Levy HB. An interdisciplinary method of classifying and monitoring medication errors. Am J Hosp Pharm 1985; 42: 1724–32PubMed Betz RP, Levy HB. An interdisciplinary method of classifying and monitoring medication errors. Am J Hosp Pharm 1985; 42: 1724–32PubMed
19.
go back to reference Hynniman CE, Conrad WF, Urch WA, et al. A comparison of medication errors under the University of Kentucky unit dose system and traditional drug distribution systems in four hospitals. Am J Hosp Pharm 1970; 27: 802–14PubMed Hynniman CE, Conrad WF, Urch WA, et al. A comparison of medication errors under the University of Kentucky unit dose system and traditional drug distribution systems in four hospitals. Am J Hosp Pharm 1970; 27: 802–14PubMed
20.
go back to reference Allan EL, Barker KN. Fundamentals of medication error research. Am J Hosp Pharm 1990; 47: 555–71PubMed Allan EL, Barker KN. Fundamentals of medication error research. Am J Hosp Pharm 1990; 47: 555–71PubMed
21.
go back to reference Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA 1990; 263: 2329–34CrossRefPubMed Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA 1990; 263: 2329–34CrossRefPubMed
23.
go back to reference Hartwig SC, Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm 1991; 48: 2611–6PubMed Hartwig SC, Denger SD, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm 1991; 48: 2611–6PubMed
24.
go back to reference Neville RG, Robertson F, Livingstone S, et al. A classification of prescription errors. J R Coll Gen Pract 1989; 39: 110–2PubMedPubMedCentral Neville RG, Robertson F, Livingstone S, et al. A classification of prescription errors. J R Coll Gen Pract 1989; 39: 110–2PubMedPubMedCentral
25.
go back to reference Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995; 274: 29–34CrossRefPubMed Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995; 274: 29–34CrossRefPubMed
26.
go back to reference Malpass A, Helps SC, Sexton EJ, et al. A classification for adverse drug events. J Qual Clin Pract 1999; 19: 23–6CrossRefPubMed Malpass A, Helps SC, Sexton EJ, et al. A classification for adverse drug events. J Qual Clin Pract 1999; 19: 23–6CrossRefPubMed
27.
go back to reference Ferner RE, Aronson JK. Errors in prescribing, preparing, and giving medicines: definition, classification, and prevention. In: Aronson JK, editor. Side effects of drugs, Annual 22. Amsterdam: Elsevier, 1999: xxiii–xxxvi Ferner RE, Aronson JK. Errors in prescribing, preparing, and giving medicines: definition, classification, and prevention. In: Aronson JK, editor. Side effects of drugs, Annual 22. Amsterdam: Elsevier, 1999: xxiii–xxxvi
28.
29.
30.
go back to reference Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 1993; 21: 506–19PubMed Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care 1993; 21: 506–19PubMed
31.
go back to reference Ferner RE, Langford NJ, Anton C, et al. Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. Br J Clin Pharmacol 2001; 52: 573–7CrossRefPubMedPubMedCentral Ferner RE, Langford NJ, Anton C, et al. Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. Br J Clin Pharmacol 2001; 52: 573–7CrossRefPubMedPubMedCentral
32.
go back to reference Langford NJ, Landray M, Martin U, et al. Testing the practical aspects of therapeutics by objective structured clinical examination. J Clin Pharmacol Ther 2004; 29: 263–6CrossRef Langford NJ, Landray M, Martin U, et al. Testing the practical aspects of therapeutics by objective structured clinical examination. J Clin Pharmacol Ther 2004; 29: 263–6CrossRef
33.
34.
go back to reference Brown TC. Sodium bicarbonate treatment for tricyclic antidepressant arrhythmias in children. Med J Aust 1976; 2: 380–2PubMed Brown TC. Sodium bicarbonate treatment for tricyclic antidepressant arrhythmias in children. Med J Aust 1976; 2: 380–2PubMed
35.
go back to reference Ferner RE, Whittington RM. Coroner’s cases of death due to errors in prescribing or giving medicines or to adverse drug reactions: Birmingham 1986-1991. J R Soc Med 1994; 87: 145–8PubMedPubMedCentral Ferner RE, Whittington RM. Coroner’s cases of death due to errors in prescribing or giving medicines or to adverse drug reactions: Birmingham 1986-1991. J R Soc Med 1994; 87: 145–8PubMedPubMedCentral
36.
go back to reference Mulchrone P. Guilty chemists; death baby pair made medicine 20 times too strong. The Mirror 2000 Mar 2: 18 Mulchrone P. Guilty chemists; death baby pair made medicine 20 times too strong. The Mirror 2000 Mar 2: 18
37.
go back to reference Johnson CE, Vigoreaux JA. Compatibility of paraldehyde with plastic syringes and needle hubs. Am J Hosp Pharm 1984; 41: 306–8PubMed Johnson CE, Vigoreaux JA. Compatibility of paraldehyde with plastic syringes and needle hubs. Am J Hosp Pharm 1984; 41: 306–8PubMed
39.
go back to reference Lee DC, Klachko MN. Falsely elevated lithium levels in plasma samples obtained in lithium containing tubes. J Toxicol Clin Toxicol 1996; 34: 467–9CrossRefPubMed Lee DC, Klachko MN. Falsely elevated lithium levels in plasma samples obtained in lithium containing tubes. J Toxicol Clin Toxicol 1996; 34: 467–9CrossRefPubMed
40.
go back to reference Pillans PI, Connor N. Tissue necrosis and necrotizing fasciitis after intramuscular administration of diclofenac. Ann Pharmacother 1995; 29: 264–6CrossRefPubMed Pillans PI, Connor N. Tissue necrosis and necrotizing fasciitis after intramuscular administration of diclofenac. Ann Pharmacother 1995; 29: 264–6CrossRefPubMed
41.
go back to reference van der Linden PD, van der Lei J, Vlug AE, et al. Skin reactions to antibacterial agents in general practice. J Clin Epidemiol 1998; 51: 703–8CrossRefPubMed van der Linden PD, van der Lei J, Vlug AE, et al. Skin reactions to antibacterial agents in general practice. J Clin Epidemiol 1998; 51: 703–8CrossRefPubMed
42.
go back to reference Woods K. The prevention of intrathecal medication errors: a report to the Chief Medical Officer. London: Department of Health, 2001: 1–24 Woods K. The prevention of intrathecal medication errors: a report to the Chief Medical Officer. London: Department of Health, 2001: 1–24
43.
go back to reference Lessons of malaria death. The Guardian 2000 Mar 3: 14 Lessons of malaria death. The Guardian 2000 Mar 3: 14
44.
go back to reference de Groen PC, Lubbe DF, Hirsch LJ, et al. Esophagitis associated with the use of alendronate. N Engl J Med 1996; 335: 1016–21CrossRefPubMed de Groen PC, Lubbe DF, Hirsch LJ, et al. Esophagitis associated with the use of alendronate. N Engl J Med 1996; 335: 1016–21CrossRefPubMed
45.
go back to reference Canet JJ, Garau J. Importance of dose and duration of betalactam therapy in nasopharyngeal colonization with resistant pneumococci. J Antimicrob Chemother 2002; 50: 39–43CrossRefPubMed Canet JJ, Garau J. Importance of dose and duration of betalactam therapy in nasopharyngeal colonization with resistant pneumococci. J Antimicrob Chemother 2002; 50: 39–43CrossRefPubMed
46.
go back to reference Hecker M, Aron D, Patel N, et al. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med 2003; 163: 972–8CrossRefPubMed Hecker M, Aron D, Patel N, et al. Unnecessary use of antimicrobials in hospitalized patients: current patterns of misuse with an emphasis on the antianaerobic spectrum of activity. Arch Intern Med 2003; 163: 972–8CrossRefPubMed
47.
48.
go back to reference Kosmidis HV, Bouhoutsou DO, Varvoutsi MC, et al. Vincristine overdose: experience with 3 patients. Pediatr Hematol Oncol 1991; 8: 171–8CrossRefPubMed Kosmidis HV, Bouhoutsou DO, Varvoutsi MC, et al. Vincristine overdose: experience with 3 patients. Pediatr Hematol Oncol 1991; 8: 171–8CrossRefPubMed
49.
go back to reference Collins DB. New Zealand’s medical manslaughter. Med Law 1992; 11: 221–8PubMed Collins DB. New Zealand’s medical manslaughter. Med Law 1992; 11: 221–8PubMed
51.
go back to reference Sussman J, Brozena S, Skop N, et al. Accidental intravenous colchicine poisoning. Ther Drug Monit 2004; 26: 688–92CrossRefPubMed Sussman J, Brozena S, Skop N, et al. Accidental intravenous colchicine poisoning. Ther Drug Monit 2004; 26: 688–92CrossRefPubMed
52.
go back to reference Deardorff DL, Schmidt CN, Wiley RA. Effect of preparation techniques on mixing of additives in intravenous fluids in nonrigid containers. Hosp Pharm 1993; 28: 306–9PubMed Deardorff DL, Schmidt CN, Wiley RA. Effect of preparation techniques on mixing of additives in intravenous fluids in nonrigid containers. Hosp Pharm 1993; 28: 306–9PubMed
54.
go back to reference Drew D, Schumann D. Homogeneity of potassium chloride in small volume intravenous containers. Nurs Res 1986; 35: 325–9CrossRefPubMed Drew D, Schumann D. Homogeneity of potassium chloride in small volume intravenous containers. Nurs Res 1986; 35: 325–9CrossRefPubMed
55.
go back to reference Beevers DG, Beevers M. Blood pressure measurement: worsening chaos. J Hum Hypertens 2000; 14: 415–6CrossRefPubMed Beevers DG, Beevers M. Blood pressure measurement: worsening chaos. J Hum Hypertens 2000; 14: 415–6CrossRefPubMed
56.
go back to reference Abernathy CM, Dickinson TC. Massive air emboli from intravenous infusion pump: etiology and prevention. Am J Surg 1979; 137: 274–5CrossRefPubMed Abernathy CM, Dickinson TC. Massive air emboli from intravenous infusion pump: etiology and prevention. Am J Surg 1979; 137: 274–5CrossRefPubMed
58.
go back to reference Eckhoff C, Didomenico R, Shapiro N. Initiating warfarin therapy: 5mg versus 10mg. Ann Pharmacother 2004; 38: 2115–21CrossRefPubMed Eckhoff C, Didomenico R, Shapiro N. Initiating warfarin therapy: 5mg versus 10mg. Ann Pharmacother 2004; 38: 2115–21CrossRefPubMed
59.
60.
go back to reference Rieder MJ, Reiner AP, Gage BF, et al. Effect of VKORC1 haplotypes on transcriptional regulation and warfarin dose. N Engl J Med 2005; 352: 2285–93CrossRefPubMed Rieder MJ, Reiner AP, Gage BF, et al. Effect of VKORC1 haplotypes on transcriptional regulation and warfarin dose. N Engl J Med 2005; 352: 2285–93CrossRefPubMed
61.
go back to reference Aithal GP, Day CP, Kesteven PJ, et al. Association of polymorphisms in the cytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding complications. Lancet 1999; 353: 717–9CrossRefPubMed Aithal GP, Day CP, Kesteven PJ, et al. Association of polymorphisms in the cytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding complications. Lancet 1999; 353: 717–9CrossRefPubMed
62.
go back to reference Lindh J, Lundgren S, Holm L, et al. Several-fold increase in risk of overanticoagulation by CYP2C9 mutations. Clin Pharmacol Ther 2005; 78: 540–50CrossRefPubMed Lindh J, Lundgren S, Holm L, et al. Several-fold increase in risk of overanticoagulation by CYP2C9 mutations. Clin Pharmacol Ther 2005; 78: 540–50CrossRefPubMed
63.
go back to reference Maxwell S, Walley T. Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow’s doctors. Br J Clin Pharmacol 2003; 55: 496–503CrossRefPubMedPubMedCentral Maxwell S, Walley T. Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow’s doctors. Br J Clin Pharmacol 2003; 55: 496–503CrossRefPubMedPubMedCentral
64.
go back to reference Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005; 293: 1223–38CrossRefPubMed Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005; 293: 1223–38CrossRefPubMed
Metadata
Title
Clarification of Terminology in Medication Errors
Definitions and Classification
Authors
Robin E. Ferner
Dr Jeffrey K. Aronson
Publication date
01-11-2006
Publisher
Springer International Publishing
Published in
Drug Safety / Issue 11/2006
Print ISSN: 0114-5916
Electronic ISSN: 1179-1942
DOI
https://doi.org/10.2165/00002018-200629110-00001

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