Medication Errors in Healthcare

Medication errors occur throughout the medication use process and carry the potential to cause severe patient harm. This chapter discusses various types of medication errors, methods of detection, components of error, and strategies for risk mitigation. Terminology frequently used in medication safety such as “adverse drug event,” “adverse drug reaction,” and “near miss” or “close call” is defined, and James Reason’s Swiss Cheese Model is explained as relating to active and latent failures. Various error detection methods such as voluntary error reporting, trigger tools, direct observation, and technology-generated data as well as diverse factors that contribute to medication errors are presented. Medication safety officers play a critical role in preventing medication errors by implementing proactive and retrospective strategies such as failure modes and effects analysis and root cause analysis. Additionally, the importance of patient education, human factors and systems engineering, and the safety culture of an institution cannot be underestimated. Patients have a right to safe care, and providers must first do no harm. Special attention is given to understanding, practicing, and systematically employing the tools and concepts presented in this chapter.