Types of Prescription Errors
Table of Contents
What Are Prescription Errors?
Prescription errors are mistakes in the prescribing, dispensing, or administration of medications that can lead to patient harm, treatment failure, or even fatal consequences. These errors can occur at any stage of the medication process—from when a doctor writes a prescription to when a patient takes the drug.Key Aspects of Prescription Errors:
- Preventable Mistakes – Most errors result from human or system failures and can be avoided.
- Potential Harm – Errors may cause adverse drug reactions, hospitalization, or death.
- Common in Healthcare – Studies suggest that medication errors affect millions of patients yearly.
Stages Where Prescription Errors Occur:
- Prescribing (Doctor writes the wrong drug, dose, or frequency)
- Transcribing (Nurse or pharmacist misinterprets the prescription)
- Dispensing (Pharmacy gives the wrong medication or instructions)
- Administration (Patient or healthcare worker takes/gives the drug incorrectly)
- Monitoring (Failure to check for side effects or adjust doses)
Why Do Prescription Errors Happen?
- Human factors (fatigue, stress, distraction)
- Poor communication between healthcare providers
- Lack of checks (e.g., no double-verification for high-risk drugs)
- System failures (e.g., no e-prescribing, unclear drug labels)
How to Reduce Errors?
✔ Electronic prescriptions (avoid handwriting issues)✔ Barcode scanning in hospitals and pharmacies
✔ Clear labeling & patient counseling
✔ Medication reconciliation (reviewing all patient drugs)
✔ Reporting & learning from past errors
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Types of Prescription Errors
1. Errors Related to Drug Selection and Prescription
These errors occur when the wrong medication is chosen, either due to a misunderstanding of the patient’s condition, confusion between drugs, or prescribing a medication that is not appropriate. Below are some specific types:a. Incorrect Drug Selection
This happens when the prescribed medication is not suitable for the patient’s medical condition or symptoms.Example:
- Prescribing an antibiotic for a viral infection (e.g., prescribing amoxicillin for the flu).
- Possible Cause: Lack of proper diagnosis, misunderstanding of guidelines, or failure to review the patient’s medical history.
b. Look-Alike/Sound-Alike (LASA) Drug Errors
Many medications have similar names, which can lead to mix-ups.Example:
- Hydroxyzine (an antihistamine) vs. Hydralazine (a blood pressure medication)
- Clonidine (used for hypertension) vs. Klonopin (clonazepam, a sedative)
- Possible Cause: Poor handwriting, verbal miscommunication, or similar packaging.
c. Incorrect Strength or Dosage Form
Prescribing the wrong strength of a drug or the incorrect formulation (tablet, liquid, extended-release, etc.).Example:
- Prescribing Metoprolol tartrate (short-acting) instead of Metoprolol succinate (extended-release), which can affect heart rate and blood pressure control.
- Prescribing a 500 mg tablet instead of a 250 mg tablet.
- Possible Cause: Lack of clarity in the prescription, confusion between different formulations, or misinterpretation of guidelines.
d. Unnecessary Medication Prescription
Sometimes, a patient is prescribed a medication they do not need, which can lead to unnecessary side effects or drug interactions.Example:
- Prescribing benzodiazepines (like Xanax) for mild anxiety when non-drug approaches (e.g., therapy) might be more appropriate.
- Possible Cause: Overprescribing due to patient demand, misdiagnosis, or failure to consider non-pharmacological treatments.
Errors Related to Dosage and Administration
These errors occur when a medication is prescribed with an incorrect dose, route, frequency, or duration, which can lead to treatment failure or serious harm. Here’s a closer look at each type:1. Incorrect Dose
Overdose – The prescribed dose is too high for the patient, which can cause toxicity or adverse effects.Example: Prescribing 100 mg of morphine instead of 10 mg, leading to respiratory depression.
Underdose – The prescribed dose is too low, making the treatment ineffective.
Example: Prescribing 2.5 mg of amlodipine instead of 10 mg for hypertension, leading to uncontrolled blood pressure.
Wrong dose based on patient factors – Not adjusting the dose based on weight, age, kidney/liver function, or other medical conditions.
Example: A child receiving an adult dose of an antibiotic, increasing the risk of toxicity.
2. Incorrect Route of Administration
The medication is prescribed to be given via the wrong route, which can reduce effectiveness or cause harm. Example Mistakes:- Prescribing potassium chloride IV push instead of IV infusion, which can cause fatal cardiac arrest.
- Ordering insulin for oral administration instead of subcutaneous injection.
3. Incorrect Frequency or Interval
The medication is prescribed at the wrong time interval, which can lead to overdosing or underdosing. Examples:- Giving warfarin twice daily instead of once daily, increasing the risk of bleeding.
- Prescribing an antibiotic every 24 hours instead of every 8 hours, leading to ineffective treatment.
4. Incorrect Duration of Therapy
The medication is prescribed for too long or too short a period. Examples:- Stopping an antibiotic too soon (e.g., only 3 days of amoxicillin for strep throat instead of 10 days), leading to resistance.
- Prescribing a corticosteroid for too long (e.g., prednisone for months without tapering), leading to adrenal suppression.
Errors Related to Patient Information
1. Incorrect Patient Details
- Prescribing or dispensing a medication for the wrong patient, which can happen due to:
- Similar patient names in the system (e.g., “John Smith” vs. “John Smyth”).
- Wrong patient profile selected in electronic health records (EHR).
- Mistaken identity in a hospital setting (e.g., switching wristbands).
2. Failure to Adjust for Patient-Specific Factors
Some medications require dose adjustments based on patient characteristics such as age, weight, kidney function, and liver function.- Incorrect weight-based dosing – Pediatric and chemotherapy drugs often require weight-based calculations.
- Kidney impairment (renal failure) adjustments – Certain drugs (e.g., aminoglycosides, metformin) need dose reduction or should be avoided.
- Liver impairment considerations – Drugs metabolized in the liver (e.g., acetaminophen, benzodiazepines) may require dose adjustments.
3. Failure to Check for Drug Allergies
Prescribing a medication the patient is allergic to, which can lead to mild reactions (rash) or severe life-threatening reactions (anaphylaxis).Example:
- A patient with a documented penicillin allergy is prescribed Augmentin (amoxicillin/clavulanate), leading to an allergic reaction.
- A sulfa-allergic patient receives Bactrim (sulfamethoxazole/trimethoprim), causing a severe rash.
Failure to Check for Drug Allergies
Prescribing a medication the patient is allergic to, which can lead to mild reactions (rash) or severe life-threatening reactions (anaphylaxis).Example:
- A patient with a documented penicillin allergy is prescribed Augmentin (amoxicillin/clavulanate), leading to an allergic reaction.
- A sulfa-allergic patient receives Bactrim (sulfamethoxazole/trimethoprim), causing a severe rash.
Incorrect or Missing Medical History
If a prescriber does not have a full medical history, they may prescribe a drug that interacts poorly with a patient’s other conditions or medications.Example:
- A patient with a history of GI bleeding is prescribed aspirin and ibuprofen, increasing the risk of a serious bleed.
Errors Related to Dispensing and Refills
These errors occur when a medication is dispensed incorrectly or refilled inappropriately, leading to treatment failure, overdose, or adverse effects. Pharmacy technicians and pharmacists play a crucial role in preventing these errors.
1. Incorrect Medication Dispensed
The wrong drug is given due to misreading the prescription or confusion between similar-sounding drug names (look-alike/sound-alike errors).
Examples:
- Hydralazine vs. Hydroxyzine – One is for blood pressure, the other for allergies.
- Clonidine vs. Klonopin – One lowers blood pressure, the other treats seizures/anxiety.
2. Incorrect Strength or Dosage Form
The right drug is dispensed, but at the wrong strength or formulation.
Examples:
- Metoprolol Tartrate (short-acting) vs. Metoprolol Succinate (extended-release) – Giving the wrong one can cause dangerous blood pressure fluctuations.
- Oxycodone 5 mg dispensed instead of 10 mg, leading to underdosing and poor pain control.
3. Incorrect Quantity Dispensed
The patient receives more or fewer tablets/capsules than prescribed.
Examples:
- A prescription for 30 tablets mistakenly filled as 60 tablets, leading to potential overdose.
- A prescription for 90 tablets dispensed as 30, requiring the patient to return earlier than expected.
4. Early or Late Refills
Early Refill: The patient receives medication too soon, leading to potential misuse or stockpiling.
Late Refill: The prescription is not refilled on time, causing missed doses and treatment failure.
Examples:
- A controlled substance (e.g., oxycodone) refilled too early, increasing the risk of abuse.
- Insulin not refilled on time, leading to uncontrolled diabetes.
5. Expired or Recalled Medications Dispensed
Medications past their expiration date or affected by a recall are mistakenly given to a patient.
Examples:
- Expired nitroglycerin dispensed, reducing effectiveness for chest pain.
- Recalled blood pressure medication (e.g., losartan contaminated with a carcinogen) given instead of a safe batch.
Errors Related to Drug Interactions and Contraindications
- Drug-Drug Interactions – Prescribing medications that interact negatively (e.g., warfarin and NSAIDs increasing bleeding risk).
- Drug-Disease Interactions – Prescribing a medication that worsens an existing condition (e.g., beta-blockers in asthma patients).
- Contraindicated Medications – Prescribing a drug that is not safe for the patient due to their medical condition or other factors.
Errors Related to Prescription Writing and Communication
- Illegible or Ambiguous Prescriptions – Poor handwriting or unclear instructions leading to misinterpretation.
- Use of Dangerous Abbreviations – Using abbreviations that can be misread (e.g., “U” for units being mistaken as “0”).
- Incomplete Prescriptions – Missing necessary information such as drug name, dose, frequency, or route.
- Verbal Order Misinterpretation – Errors due to misheard or miscommunicated verbal prescriptions.
Errors Related to Prescription Writing and Communication
- Illegible or Ambiguous Prescriptions – Poor handwriting or unclear instructions leading to misinterpretation.
- Use of Dangerous Abbreviations – Using abbreviations that can be misread (e.g., “U” for units being mistaken as “0”).
- Incomplete Prescriptions – Missing necessary information such as drug name, dose, frequency, or route.
- Verbal Order Misinterpretation – Errors due to misheard or miscommunicated verbal prescriptions.
