1. MEDICATION ErrOr
(ME)
Prepared by,
Hema Latha Sinniah
Pegawai Farmasi U41
PKD Sabak Bernam

2. Definition
What to/ not to report
ME Types
ME Reporting Flow Chart
ME Report Form
ME Examples
Error Reduction Strategies

3. Any preventable event that may
cause or lead to inappropriate
medication use or patient harm
while the medication is in control of
the healthcare professional, patient
or consumer
NCCMERP, US
DEFINATION MEDICATION
ERROR . .

4. When errors are common, Health Care is
Hazardous.
We need to reduce the risk of error,
predominantly by improving systems.
Accepting that errors cannot be eliminated, we
need to
Encourage reporting
Learn from errors
Manage the repercussions to the patient,
caregivers, and any other affected groups.

5. Non-punitive
All levels of healthcare
providers may report
 Involve both public
and private sectors
Includes hospitals,
clinics,
community pharmacies

6. Maybe related to professional practice,
healthcare products, procedures and
systems including:
prescribing, order communication,
product labeling, packaging,
compounding, dispensing, distribution,
administration, monitoring and use
6

7. Medication errors can be
committed (or contributed to) by
Anyone who handles medicine
Physicians/doctors, dentists,
pharmacists, other healthcare
providers, patients, caregivers etc

8. Error is inevitable because of human
limitations
- Limited memory capacity
- Limited mental processing capacity
- Negative effects of fatigue and other
physiological stressors

9. Look at systems involved in
medication error
Why?
and not Who?

10. Risks that can lead to errors or near
misses
Sound-alike names or look alike
packages
Ambigous product labels
Use of error prone abbreviations
Error-prone functions in cpoe systems

11. 1. Look alike drugs which can be in
terms of product size, packaging and
also colour on the label, example ;

12. Hyoscine butylbromide 20mg/ml injection &
Prochlorperazine mesylate 12.5mg/ml injection

13. Potassium chloride 10% w/v injection &
Sodium bicarbonate 8.4% w/v injection

16. Simvastatin, Atorvastatin, Rosuvastatin
Omeprazole,Pantoprazole,Esomeprazole
Perindopril, Enalapril, Ramipril
Cefotaxime, Cefuroxime
Neurobion, Neurontin

17. 3. Illegible handwriting, which may lead to
misinterpretation of doctor’s prescription
such as drug’s name, dosage, frequency,
example;

20. Medication error can be broadly classified as :
Prescribing errors
Dispensing errors
Administration errors

21. Inadequate knowledge about drug interaction &
contraindication
Not considering individual patient factor
-E.g. allergies,pregnancy,co-morbidities,other
med
Miscommunication(written,verbal)
Documentation-illegible,incomplete,ambiguous
Incorrection calculation
Incorrect data entry when using computerized
Physian Order Entry(CPOF)

22. Wrong stock selection
Self-checking
Incorrect storage of medicines,wrong shelf,etc
Not following checking protocols
Staff distraction
Too many tasks at once
Too few staff
Poorly trained staff
Bad communication between staff

23. Wrong patient
Wrong drug
Wrong time
Wrong dose
Wrong route
Omission,failure to administer

24. PrescribingPrescribing
errorerror
Incorrect drug productIncorrect drug product
selection (based onselection (based on
indications, CI,knownindications, CI,known
allergies, existing drugallergies, existing drug
therapy), dose,dosagetherapy), dose,dosage
form, quantity, route orform, quantity, route or
rate of administration,rate of administration,
conc, or instructions forconc, or instructions for
use authorised byuse authorised by
physician; illegible Rx orphysician; illegible Rx or
med orders that lead tomed orders that lead to
errorserrors

25. OmissionOmission
errorerror
The failure to administerThe failure to administer
an ordered dose to aan ordered dose to a
patient before the nextpatient before the next
ordered dose or failure toordered dose or failure to
prescribe a drug productprescribe a drug product
that is indicated.that is indicated.
The failure to administerThe failure to administer
an ordered dose excludesan ordered dose excludes
patient’s refusal andpatient’s refusal and
clinical decision or otherclinical decision or other
valid reason not tovalid reason not to
administer.administer.

26. Wrong timeWrong time
errorerror
Unauthorised/Unauthorised/
wrong drugwrong drug
errorerror
Administration ofAdministration of
medication outside amedication outside a
predefined time intervalpredefined time interval
from its scheduledfrom its scheduled
administration timeadministration time
Dispensing orDispensing or
administration to theadministration to the
patient of medication notpatient of medication not
authorised by a legitimateauthorised by a legitimate
prescriberprescriber

27. Dose errorDose error Dispensing or administrationDispensing or administration
to pt of a dose that is > or<to pt of a dose that is > or<
than amount ordered bythan amount ordered by
prescriber or administrationprescriber or administration
of multiple doses to ptof multiple doses to pt
Dosage formDosage form
errorerror
Dispensing or administrationDispensing or administration
to pt of a drug product into pt of a drug product in
diff dosage form than thatdiff dosage form than that
ordered by prescriberordered by prescriber

28. DrugDrug
preparationpreparation
errorerror
Drug product incorrectlyDrug product incorrectly
formulated or manipulatedformulated or manipulated
before dispensing orbefore dispensing or
administrationadministration
Route ofRoute of
administrationadministration
errorerror
Wrong route ofWrong route of
administration of theadministration of the
correct drugcorrect drug
AdministrationAdministration
techniquetechnique
errorerror
Inappropriate procedure orInappropriate procedure or
improper technique in theimproper technique in the
administration of a drugadministration of a drug
other than wrong routeother than wrong route

29. DeterioratedDeteriorated
drug errordrug error
Dispensing or administrationDispensing or administration
of a drug that has expired orof a drug that has expired or
the physical or chemicalthe physical or chemical
dosage form integrity hasdosage form integrity has
changedchanged
MonitoringMonitoring
errorerror
Failure to review aFailure to review a
prescribed regimen forprescribed regimen for
appropriateness & detectionappropriateness & detection
of problems, or failure to useof problems, or failure to use
appropriate clinical or labappropriate clinical or lab
data for adequatedata for adequate
assessment of pt response toassessment of pt response to
prescribed therapyprescribed therapy
29

30. ComplianceCompliance
errorerror
Inappropriate patientInappropriate patient
behavior regardingbehavior regarding
adherence to a prescribedadherence to a prescribed
medication regimenmedication regimen
OtherOther
medicationmedication
errorerror
Any medication error thatAny medication error that
does not fall into one of thedoes not fall into one of the
above predefined typesabove predefined types

32. 18. Medication Error (ME) Reporting Form
MEDICATION ERROR (ME) REPORTING FORM
Reporters do not necessarily have to provide any individual identifiable health information, including names of
practitioners, names of patients, names of healthcare facilities, or dates of birth (age is acceptable)
1. Date of event Time of event Place /Location of event
2. Please describe the error. Include description/sequence of events, type of staff involved, and
work environment (e.g. change of shift, short staffing, during peak hours). If more space is
needed, please attach a separate page.
3. Did the error reach the patient? (Tick appropriate box) Yes No
4. Was the incorrect medication, dose or dosage form
administered to or taken by the patient? (Tick appropriate box) Yes No
4 .1 Circle the appropriate Error Outcome Category (select one – see Guide for details)
A B C D E F G H I
4 .2 Describe the direct result on the patient (e.g., death, type of harm, additional patient
monitoring).
5. Indicate the possible error cause(s) and contributing factor(s) (e.g., abbreviation, similar
names, distractions, etc).
6. What category of staff or healthcare provider made the initial error?
7. Indicate if other provider (s) were also involved in the error (category of staff perpetuating
error)
32

33. Medication Error (ME)
Report Form
 Hospital Pharmacy
 Medication Safety,
Pharmaceutical Services
Division,MOH
 www.pharmacy.gov.my

34. Date and time of event
Type of facility
Private/ government
hospital/clinic/pharmacy
Location of event:
- ward
- pharmacy
- A& E
- OT/ ICU etc

35. Description of event
- sequence of events
- work environment (peak hour, change of
shift)
- details (what? how? of the incident)
Attach separate page if more space is needed

36. In which process error occur
Prescribing/Dispensing/Administration/
Others
Did error reach patient Y/N
Incorrect med, dose or dosage administered
or taken by patient
Describe direct result on patient
eg. death, admission into hospital, drugs
prescribed to treat error

37. Did an actual error
occur?
Category C
Circumstances or events that
have the capacity to cause
error
Did the error reach the
patient? *
Did the error contribute to or
result in patient death?
Was the patient harmed?
Did the error
require an intervention necessary
to sustain life ?
Did the error require initial
or prolonged hospitalization
Was the harm temporary
?
Was the harm permanent ?
Category H
Category G
Category E Category F
Was intervention to
preclude harm or extra
monitoring required ?
Category B
Category A
Category I
Category D
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
NO
YES
YES
NO
YES
YES
Classification of Medication Error SeverityClassification of Medication Error Severity
NO ERRORNO ERROR
Category ACategory A Potential error, Circumstances/events havePotential error, Circumstances/events have
potential to cause incidentpotential to cause incident
ERROR, NO HARMERROR, NO HARM
Category BCategory B Actual Error – did not reach patientActual Error – did not reach patient
Category CCategory C Actual Error – caused no harmActual Error – caused no harm
Category DCategory D Additional monitoring required – caused noAdditional monitoring required – caused no
harmharm
ERROR HARMERROR HARM
Category ECategory E Treatment/Intervention required –causedTreatment/Intervention required –caused
temporary harmtemporary harm
Category FCategory F Initial/prolonged hospitalization –causedInitial/prolonged hospitalization –caused
temporary harmtemporary harm
Category GCategory G Caused permanent harmCaused permanent harm
Category HCategory H Near death eventNear death event
ERROR, DEATHERROR, DEATH
Category ICategory I DeathDeath
An error of omission does reach theAn error of omission does reach the
patientpatient
All ME reports should be sent to :
Medication Safety Centre
Pharmaceutical Services Division , Ministry of Health
P.O. Box
924, Jalan Sultan,
46790 Petaling Jaya, Selangor.
19. GUIDE FOR CATEGORIZING MEDICATION ERRORS
37

38. Possible contributing factor (s)
Example:
- Sound alike or look alike drug
- Look alike packaging
- Different strength of same drug
- Unclear instruction on Rx
- Illegible handwriting

39. Category of staff made initial error?
Other category involved
Category of staff,provider or
individual who discovered the
error/potential error
Example: Doctor, pharmacist, staff
nurse, pharmacist assistant, asst
medical officer, PRP, trainee MA or SN

40. Patient’s particulars
Do not provide patient’s name
Info needed = age, M or F, diagnosis
Product 1 intended (prescribed)/ error
brand name, generic name, dose,
freq,duration, route
similar packaging- manufacturer, dosage
form, strength, container type

41. Relevant materials can be provided
- copy of Rx, label of product, picture of
product involved
Recommendations/ preventive actions
taken
Reporter’s details

42. P.O Box 924,
Jln Sultan
46790 Petaling Jaya
Tel : 03-
7841 3200
Fax: 03-
79682268 Online
Sistem pengurusan
farmasi
ME
MedSC

44. Administrative errors
Examples:
 no prescribers stamp
 no countersignature for category
A medicines
 Medicines not stocked

45. Tall Man Lettering
Writing part of a drugs name in upper
case letters to help distinguish sound
alike, look alike drugs from one another
niMODIpine - niFEDIpine
METOprolol - BISOprolol
predniSONE – prednoso LONE
Currently the Pharmacy Department has
labeled the drug bins using this format

46. Medication Error Alert
Alerts should be issued out whenever
errors occur so that the information will
be disseminated for others to be more
careful in dealing with the medication
involved.
This alerts can be issued via emails,
memo and also posters.

47. Poster of product change
Circulate posters on product changes so
that all pharmacy staff will know that
certain medications had changed in
appearance.

48. Colour-coded bins
The bin label is differentiated according
to pharmacological group.
The colour coding concept is adapted
from 5S Guidelines 2011 published by the
Pharmaceutical Service Division, Ministry
of Health Malaysia.

49. Prompt alert in e-HIS
Prompt alert in the e-HIS were created
for medications which has potential of
being mistakenly prescribed by doctors.
Most of the drugs involved are
medication which sound alike.

50. Enable the healthcare providers & institutions to
learn about :
• Potential risks - Risk hidden in the processes used
• Actual errors - Errors that happen during patient
care
• Causes of errors - Underlying weaknesses in
systems & processes that explain why errors
happened
• Prevention - Ways of preventing recurrent events

52. THANK YOU FOR
YOUR ATTENTION
MEDICATION ERRORS ARE PREVENTABLE!

53. What are the types of medication error? Give 3
examples.
What are the steps taken to overcome this error?
Name 2 of them.