An analysis of death rates over an eight year period published in the British Medical Journal last year suggested that medical errors are the third leading cause of deaths in the United States.

However, the researchers cautioned that most errors are not due to incompetent doctors, but rather, represent systemic problems that include poorly co-ordinated or fragmented care, variations in practice that lack accountability, and absence or under-use of safety nets and other protocols.

Medication errors are the single most preventable cause of harm to patients. They are committed by doctors, pharmacists, nurses, manufacturers, caregivers and patients.

There were 3,526 medication errors reported to the Patient Safety Unit of the Health Ministry in 2014-2015, with 248,307 near misses in the same period.

A near miss is a medication error that was detected and action taken before the medicine was received by or administered to a patient. As the reports were primarily from the ministry’s facilities, and not all of them reported, it is likely that the numbers are the tip of the iceberg.

The outcomes of the medication errors were not available in the public domain.

The Malaysian National Patient Safety Council defines medication error as “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 an event may be related to professional practices, healthcare products, procedures and systems, including prescribing, order communication, product labelling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use”.

There are several steps between a doctor’s decision to prescribe and the patient’s receipt of the medication:

• Prescribing: the doctor selects the appropriate medication, its dose and frequency of administration.

• Transcribing: in a paper-based system, an intermediary – a pharmacist or dispenser – in the hospital or outpatient setting reads and interprets the prescription correctly.

• Dispensing: the pharmacist or dispenser checks the prescription and then releases the appropriate quantity of the medication in the correct form.

• Administration: the correct medication is supplied to the correct patient at the correct time.

This is usually the nurse’s responsibility in the hospital, but in the community, patients or caregivers are responsible.

Causative factors

Medication errors include prescribing errors, dispensing errors, administration errors, monitoring errors and deteriorated medicines. These errors occur because of multiple factors in the complex healthcare delivery system.

In most instances, medication errors cannot be attributed to a single person.

The causative factors include misinterpreted handwriting; confusing medication names; confusing medication labels and packaging; lack of employee knowledge; heavy workload; lack of safety culture in the work environment; lack of patient understanding about a medicine’s directions; and poor communication.

The prevention of medication errors requires specific steps at every stage.

The majority of errors occur at the prescribing, transcribing and administration stages.

The recommendations of the US Agency for Healthcare Research and Quality, which have been adopted in many countries, are:

• Prescribing – Avoidance of unnecessary medications by adhe-rence to conservative prescribing principles; computerised provider order entry, especially when paired with clinical decision support systems; medication reconciliation when there are transitions in care.

• Transcribing – Computerised provider order entry to eliminate handwriting and transcription errors.

• Dispensing – Oversight of medication dispensing process; use of “Tall man” lettering and other strategies to minimise confusion between look alike and sound-alike medications.

• Administration – Adherence to “Five Rights” of medication safety (administering the Right medica-tion, in the Right dose, at the Right time, by the Right route, to the Right patient); barcode medication administration to ensure medica-tions are given to the correct patient; minimise interruptions to allow nurses to administer medications safely; smart infusion pumps for intravenous infusions; patient education and revised medication labels to improve patient comprehension of administration instructions.

During dispensing, the pharmacist or dispenser checks the prescription and then releases the appropriate quantity of the medication in the correct form. — Filepic

During dispensing, the pharmacist or dispenser checks the prescription and then releases the appropriate quantity of the medication in the correct form. Photo: Filepic

What patients and caregivers can do

While the managers and healthcare staff are trying to reduce the likelihood of medication errors, there is much that patients and their caregivers can do.

Know what errors can occur. The US Food and Drug Administra-tion found that the common fatal errors were due to administration of the wrong dose or wrong medicine, and using the wrong route of administration.

Performance and knowledge deficits and communication errors were the common causative factors.

Senior citizens and children were the most vulnerable; the former because of multiple medications and the latter because accurate calculations of the dose are vital.

It is essential to know the medicines prescribed. This includes its name, what it looks like and whether it is the original product or a generic.

It would be preferable to know where it was manufactured and who the manufacturer is, especially when there are counterfeit medications.

One should know the reason for the prescription, how and when to administer it, how long to take it and the time needed to take effect.

One should be informed of what to avoid, the side effects and interactions of the medicine, and what to do should they occur.

It is important to know how and under what conditions one should cease taking the medicines.

Do not stop or use the medicine differently without consulting the doctor.

One should know what to do if a dose is missed and whether any tests or monitoring are required.

As it may be challenging to remember everything, it is advisable to always ask for written instructions.

Keeping a list of all allergies and medications consumed, including over-the-counter ones, and making it available to all doctors and pharmacists is essential. The oft-forgotten notifications include pregnancy, vitamins, birth control pills, sleeping pills and herbal products.

It is advisable to get all medications from the same supplier, whether it be a hospital, clinic or pharmacy.

Good communication with the doctor, pharmacist and nurse go a long way in helping recovery from an illness.

It is important to remember that communications always involve both parties as the doctor, pharmacist, and nurse cannot read a patient’s mind. If in doubt, ask until the answer is satisfactory.

Remember, patients and their caregivers have a critical role in reducing medication errors.


Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of any organisation the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.