Key Points on Medication Errors

• Medication errors are the most common type of medical error in the United States.¹
• Medication use is extremely common in emergency care, increasing opportunities for error.
  • An estimated 76.3% of ED visits involve a medication or immunization.⁶
• The emergency department (ED) is a high-risk environment for medication errors and is the third most common site where they occur.²
  • Approximately 3.6% of ED patients receive an inappropriate medication dose.³
  • About 5.6% of ED prescriptions are inappropriate.³
  • Some studies estimate that up to 16% of all ED prescriptions involve an error.⁴
  • MEDMARX data show that 49% of ED medication errors reach the patient.⁵
  • Approximately 3% of ED medication errors result in patient harm.⁵

• Pediatric patients are particularly vulnerable to medication errors.⁹
  • Weight-based dosing and developmental variation increase risk.
  • Ten-fold dosing errors are well described in pediatric care.
• Often caused by decimal point misplacement
• More likely in smaller children when a ten-fold overdose fits into a single syringe
  • Variable medication concentrations increase risk (e.g., ketamine 10 mg/mL, 100 mg/mL, 500 mg/mL).
  • Additional contributors include paper-based ordering, manual dose calculations, and pump programming errors.
  • Use of standardized dosing tools and color-coded systems is associated with reduced errors.

• Distractions and interruptions are a leading cause of medication errors in the ED.⁷
  • Errors may occur during ordering, procuring, or administering medications.
  • Common contributing factors include illegible orders, incorrect dose calculations, and wrong medication selection.
• ED crowding and high workload are associated with increased medication errors.¹⁰
  • Time pressure, interruptions, multitasking, and cognitive overload increase risk.

High-alert medications are those with an increased risk of causing serious patient harm when used in error.²

• Classes commonly encountered in emergency care include:
  • Adrenergic agonists and antagonists (IV)
  • General anesthetic agents (IV and inhaled)
  • Antiarrhythmics (IV)
  • Antithrombotic agents (including anticoagulants, thrombolytics, and direct thrombin inhibitors)
  • Chemotherapeutic agents
  • Hypertonic dextrose (≥20%)
  • Insulin (IV and subcutaneous)
  • Moderate sedation agents (IV and oral)
  • Opioids (IV, oral, and transdermal)
  • Neuromuscular blocking agents
  • Radiographic contrast agents
  • Hypertonic saline (>0.9%)

• Injection medication safety principles include:
  • One needle, one syringe, one patient
  • Use single-dose vials whenever possible
  • If more than two vials are required, reassess dose and concentration
  • Disinfect vial stoppers and IV hubs before access
  • Date and label all multi-dose vials
  • Perform hand hygiene before and after glove use
  • Prepare medications in the pharmacy whenever feasible

• Evidence-based strategies to reduce medication errors in the ED include:⁸
  • Integration of ED-based pharmacists
  • Computerized provider order entry (CPOE), recognizing potential unintended consequences
  • Medication reconciliation for all ED patients
  • Clear documentation of allergies
  • Clear documentation of contraindicated medications
  • Special storage and warning labels for neuromuscular blocking agents
  • Separation of look-alike and sound-alike medications
  • Independent double checks for high-alert medications
• Double-check systems may reduce high-risk errors but can be undermined by complacency and workflow fatigue.
  • Independent verification and a strong safety culture are critical for effectiveness.

1. Institute of Medicine. To Err Is Human: Building a Safer Health System. National Academies Press; 2000.
   https://nap.nationalacademies.org/catalog/9728/to-err-is-human-building-a-safer-health-system
2. Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Preventing Medication Errors. National Academies Press; 2007.
   https://nap.nationalacademies.org/catalog/11623/preventing-medication-errors
3. Pham JC, Story JL, Hicks RW, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. Ann Emerg Med. 2011;57(5):485–492.
   https://pubmed.ncbi.nlm.nih.gov/21429414/
4. Patanwala AE, Warholak TL, Sanders AB, et al. A prospective observational study of medication errors in a tertiary care emergency department. Am J Health Syst Pharm. 2010;67(15):1237–1245.
   https://pubmed.ncbi.nlm.nih.gov/20651355/
5. Santell JP, Hicks RW, Cousins DD, Williams RL. Medication errors in the emergency department: results of the MEDMARX reporting system. Ann Emerg Med. 2003;42(2):231–238.
   https://pubmed.ncbi.nlm.nih.gov/12729405/
6. Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. Natl Health Stat Report. 2008;(7):1–38.
   https://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf
7. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. BMJ Qual Saf. 2010;19(4):284–292.
   https://pubmed.ncbi.nlm.nih.gov/20693240/
8. Cohen MR, ed. Medication Errors. 2nd ed. American Pharmacists Association; 2007.
   https://www.pharmacist.com/Practice/Patient-Care-Services/Medication-Safety
9. Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2001;107(6):1431–1436.
   https://pubmed.ncbi.nlm.nih.gov/11483782/
10. Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. Ann Emerg Med. 2010;55(4):337–343.
    https://pubmed.ncbi.nlm.nih.gov/20381282/