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Medication Administration Errors: How to Address Them?


Root-cause analysis is a structured method used to determine the possible causes of an undesirable event or problem. This method is used to consider all possible scenarios and reasons identified by the expert group. It allows the necessary consensus to be established on the most likely causes, which can then be verified empirically or by evaluating the available data. This paper aims to describe and analyze medication administration errors as a primary safety issue in hospitals and develop an improvement plan to address this concern.

Analysis of Medication Errors

Errors in prescribing medications contribute to an increase in morbidity and mortality. According to rough estimates, these errors cost the US healthcare system about $177 billion (depending on the definition) per year (Haroutounian, 2019). Errors in prescribing medications may include an incorrect choice of the drug, its administration in an inadequate dose, wrong dosage regimen, and duration of therapy. Sometimes, these mistakes result in fatal outcomes; thus, they need to be prevented.

Pharmacy employees may incorrectly read the prescription, as a result of which the wrong drug or its dosage will be issued. Incorrect instructions to the patient or improper administration of the drug by a medical professional or patient. Incorrect storage of the medication by a pharmacy employee or patient leads to a decrease in its activity (Mazhar et al., 2018). The use of a drug with an expired expiration date leads to a decline in its action. Incorrect administration of the drug by the patient (Haroutounian, 2019). Faulty transmission of information specified in the prescription between different suppliers.

Mistakes in prescribing medications are also possible in medical institutions. In particular, the drug may be prescribed to the wrong patient at the wrong time, or the wrong method of administration may be mistakenly prescribed. Some drugs should be administered intravenously slowly; some cannot be administered in parallel. If such errors are detected, it is necessary to immediately inform the doctor and get the advice of a pharmacist.

Electronic drug dispensing systems reduce the likelihood of such errors (Strom et al., 2019). The use of expired medicines is quite common. Expired drugs may be ineffective, and some of them (for example, acetylsalicylic acid or tetracycline) may pose a danger after the expiration date. Errors in prescribing medications often occur due to the lack of information in patients about how to take the drug correctly. As a result, they may mistakenly take the wrong drug or the wrong dose of the drug.

Another common cause of errors is the inaccurate transmission of the information specified in the prescription when transferring a patient from one institution to another or transferring from one doctor to another. For example, when the data is transferred from a hospital to a rehabilitation center, from a nursing home to a hospital, or from a specialist doctor to a primary care provider. Communication between various medical professionals who are busy with work usually requires active efforts, and when transferring a patient, changes in the admission scheme are common (Haroutounian, 2019).

Increased attention to the means of communication can help reduce the risk of such errors. The threat has been reduced through various official drug approval programs, such as preparing a complete list of current medications each time a patient is transferred from one facility to another.

Application of Evidence-Based Strategies to Reduce Medication Errors

The analysis of special studies devoted to the study of medical errors in general and doctors’ errors in prescribing medicines, in particular, indicates that they are based on the shortcomings of the system of training and advanced training of medical personnel in pharmacotherapy. Moreover, it owes to the untimely and insufficient provision of the necessary information to medical and pharmaceutical workers about possible adverse side effects of medicines (Mazhar et al., 2018). It also refers to the shortcomings in the organization and functioning of drug safety control systems.

One of the effective evidence-based strategies implemented is providing medical and pharmaceutical healthcare professionals with objective, independent information about possible adverse reactions to medicines. Such knowledge also includes the data about the interaction of medications with each other and with biologically active substances (Alanazi et al., 2019). Another effective tactic to use is improving the safety control system of medicines both at the federal and regional levels and directly in medical and preventive institutions (Strom et al., 2019).

At the same time, it is imperative, along with using the method of spontaneous messages, to introduce into practice such modern methods of detecting adverse side effects of medicines as active monitoring. This strategy also includes the analysis of registries and databases containing information on morbidity and mortality and the analysis of the dependence of pharmacotherapy complications on drug consumption. It is also essential to recognize the importance of patient safety in order to reduce the costs associated with eliminating the consequences of harm caused to patients and improve the efficiency of the functioning of the health system.

Improvement Plan

The improvement plan consists of several actions that should be elaborated on and undertaken by a number of healthcare professionals. Firstly, care facilities should develop databases comprised of the names of every possible medication and its dosage. In addition, clinics and hospitals must have electronic health records (EHS) in order to know each patient’s drug, dosage, and frequency (Riaz et al., 2017). By allowing the maximum use of technologies, it is possible to avoid uncompromising mistakes. This strategy will help reduce the number of medication errors since doctors and other medical professionals will be able to allocate medical adequately.

Third parties are necessary to participate in the improvement plan activation. Pharmacists should also conduct a “review of prescribed medications” before prescribing a drug to a patient, including the interaction of different medications, the dosage and duration of treatment, allergic reactions, and drug abuse (Riaz et al., 2017). Vendors must take part in the process, too; for instance, they should track the expiration date when selling it to the medical facility (Alanazi et al., 2019). Finally, healthcare workers must double-check the prescription since the human factor is sometimes the cause of mistakes. The provision of safe services will also help restore and strengthen public confidence in the health system.


In summation, medication administration is a common issue causing numerous outcomes. Medical errors significantly increase the cost of treating a patient and increase the duration of hospitalization. Partial information in the medical history of a patient tends to lead to the interruption of previously chosen treatment or therapy. In addition, the administration of wrong treatment regimens also increasingly tangles the identification of adverse drug responses. Such mistakes should be prevented in order to boost the nation’s health, cut expenses, and improve the healthcare system. The improvement plan consists of consecutive steps to be followed by a medical facility to ensure drug administration safety.


Alanazi, A.A., Alomi, Y.A., Almaznai, M.M., Aldwihi, M., Aloraifi, I.A., & Albusalih, F.A. (2019). Pharmacist’s intervention and medication errors prevention at pediatrics, obstetrics and gynecology hospital in East Province, Saudi Arabia. International Journal of Pharmacology and Clinical Sciences, 8(2), 122-128. Web.

Haroutounian, S. (2019). Preventing medication errors at home. Oxford University Press.

Mazhar, F., Haider, N., Ahmed Al-Osaimi, Y., Ahmed, R., Akram, S., & Carnovale, C. (2018). Prevention of medication errors at hospital admission: a single-centre experience in elderly admitted to internal medicine. International Journal of Clinical Pharmacy, 40(6), 1601–1613. Web.

Riaz, M. K., Riaz, M., & Latif, A. (2017). Review – Medication errors and strategies for their prevention. Pakistan Journal of Pharmaceutical Sciences, 30(3), 921-928.

Strom, B., Hennessy, S., & Kimmel, S. (2019). Pharmacoepidemiology. John Wiley & Sons.

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"Medication Administration Errors: How to Address Them?" ApeGrade, 6 Mar. 2023, apegrade.com/medication-administration-errors-how-to-address-them/.

1. ApeGrade. "Medication Administration Errors: How to Address Them?" March 6, 2023. https://apegrade.com/medication-administration-errors-how-to-address-them/.


ApeGrade. "Medication Administration Errors: How to Address Them?" March 6, 2023. https://apegrade.com/medication-administration-errors-how-to-address-them/.


ApeGrade. 2023. "Medication Administration Errors: How to Address Them?" March 6, 2023. https://apegrade.com/medication-administration-errors-how-to-address-them/.


ApeGrade. (2023) 'Medication Administration Errors: How to Address Them'. 6 March.

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