A new study of prescription medication errors at primary care doctors’ offices found that written and verbal communication problems were the most common causes of the errors, followed by knowledge deficits by doctors, pharmacists and patients.

Over a 10-week period, researchers at the Cleveland Clinic collected data related to 507 prescription medication events involving patients of all ages. 70 percent of the events involved medication errors without adverse events, 27 percent involved adverse medication outcomes without errors, and 2.4 percent involved both.

At least 11 percent of the errors involved physical or emotional harm to a patient. Of those patients known to have been harmed, eight required hospitalization and three sustained a permanent injury. The causes of the hospitalization were medication errors (3 cases), adverse drug events (4 cases), or both (1 case).

The most common type of prescription involved was cardiovascular medication. In 18 percent of the cases, the errors involved two or more prescriptions. The number of errors varied widely among the practices studied, but the average number of medication errors reported was 14 per week.

Transcription Errors, Verbal Communication Problems, Lack of Knowledge Most Common Issues

In 41 percent of the cases, the cause was a written or verbal communication problem. 22 percent of the time, lack of knowledge by the doctor, pharmacist or patient was the cause of the error.

Generally, the issues involving lack of knowledge included those where a doctor prescribed an unavailable dosage or form of the medication, or where the patient or pharmacist didn’t have information about currently prescribed medications or doses. In one case, a patient who could not read took four times the correct dose.

The report found that the source of the prescription error was equally divided among four areas: errors by the prescribing physician, errors in implementation of the prescription order, patient errors, and documentation errors, meaning that the medical record or list of home medications was not up to date.

The types of errors reported, broken down by percentage of occurrences, included:

Prescriber errors: 28 percent

• Improper dosage described: 13 percent
• Wrong medication prescribed: 5 percent
• Wrong patient’s name on prescription: 4 percent
• Medication prescribed was contraindicated: 2 percent
• Prescription called in to wrong pharmacy: less than 1 percent

Pharmacy errors: 24 percent

• Incorrect drug label: 8 percent
• Prescription filled in the wrong dosage: 7 percent
• Incorrect drug dispensed: 5 percent
• Medication never dispensed: 3 percent
• Long-term medication not continued: 1 percent

Patient errors: 20 percent

• Patient did not take medication correctly: 18 percent
• Patient continued taking medication after told to stop: 1.5 percent
• Different doctors mixed up the medications: less than 1 percent
• Prescription sample or over-the-counter medication incorrectly supplied: less than 1 percent

Failure to monitor: 4 percent

Documentation errors: 24 percent

A medication error can have devastating or even deadly consequences. The best thing patients and their families can do is to focus on good communication at every step:

• Tell your doctor about all your medications, both prescription and over the counter.
• When given a new medication, ask about the risks, benefits, and possible interactions with existing medications.
• Make sure you understand the dose, instructions and timing before you leave the doctor’s office.
• Ask your doctor what side effects to expect, and anything to watch out for.
• Make sure your pharmacist fills the prescription as you expected. If not, verify it with your doctor.

When your health and safety are on the line, there are no stupid questions.

Sources:

• Becker’s Hospital Review, “Prototype IT System Shows Miscommunication, Lack of Knowledge Cause Medication Errors and Adverse Drug Events,” Jaimie Oh, December 7, 2010
• Annals of Family Medicine, 2010 Nov-Dec; 8(6):517-25, “Field Test Results of a New Ambulatory Care Medication Error and Adverse Drug Event Reporting System-MEADERS,” John Hickner, MD, et al., Department of Family Medicine and the Medicine Institute, Cleveland Clinic