Medication errors

Definition

A medication error is an unintentional action or omission involving a medicinal product during the treatment process. Medication errors could lead to or heighten the risk of undesirable events occurring in patients. In most cases, they are due to errors in prescribing, dispensing, storing, preparing and administering medicinal products. Medication errors are classified as follows:

• Confirmed errors, when the medication error actually occurred
• Intercepted errors, when the medication error is detected (intercepted) before the product is administered to the patient
• 'Potential' errors, or 'risks of error', when observations enable the identification of a potential risk for the patient (e.g., medicinal products with similar packaging or names)

Examples of medication errors

There are 4 major categories of medication error:

• Wrong medication
• Wrong dose (dosage, formulation, quantity)
• Wrong route of administration
• Wrong patient

Examples include: confusing two different medicinal products; using the wrong route of administration; taking too large a dose; and, mistakenly ingesting a medicinal product (e.g. by a child); etc.

Why should a medication error or medication error risk be reported?

Medication errors can in some cases result in serious undesirable effects.

When a confirmed or intercepted error, or an error risk, is reported, the information can be used to assess what caused the error, and to put in place measures to reduce the risk of the error occurring again in the future. These measures are varied and depend on the type of error.

Measures may be 'preventive' (e.g., packaging or labelling changes, special storage arrangements, prescription and/or administration restrictions, etc.) or 'corrective' (e.g., replacing or withdrawing a medicinal product, specific training for one or more categories of staff, etc.).

By analysing why an error occurred, all of the factors that contributed to its occurrence, or the risk of it occurring, can be taken into account. And once the contributing factors have been identified, more suitable measures can be proposed.

Who receives your medication error report, and how to file a report

The Division of Pharmacy and Medicines (Division de la pharmacie et des médicaments) is the recipient of all medication error reports, regardless of whether the errors are associated with undesirable effects or not.

Medication errors, whether confirmed or potential, and medication error risks, can be reported via pharmacovigilance@ms.etat.lu or crpv@chru-nancy.fr.