(Except from The Medication A.R.E.A.S. Bundle Handbook)

The Stages of the Medication Use Process Where Medication Errors Can Occur


The 1999 Institute of Medicine (IOM) report “To Err Is Human: Building a Safer Health System” found that medication-related errors were a significant cause of morbidity and mortality in the United States, accounting for at least 1.5 million medication-related events or preventable medication-related injuries that occur yearly. Medication errors have been estimated to account for 1.9 million hospital stays, increased length of hospital stays, the most common causes of inpatient complications, and about $3.5 billion in hospital costs. In outpatient/ ambulatory  settings,  medication  errors  are  the  most  common post-discharge complication, resulting in 3.5 million office/ambulatory visits, and 1 million emergency department visits.

Medication errors also account for one out of every 131 outpatient deaths, and one out of 854 inpatient deaths, totaling more than 7,000 deaths annually. Based on these and other findings, the IOM issued   a report in 2007 on medication safety called “Preventing Medication Errors.” This report focused on issues such as the importance of reducing medication errors, providing clinicians with information and decision- support tools, and processes to reduce medication errors and adverse outcomes.

Medication-related errors are not just a problem in the United States. Several studies from various countries have reported that 3.7–16.6% of total hospital admissions were associated with adverse events, a substantial proportion of which were attributed to medication use. With the increased reliance on medication therapy as the primary intervention for chronic and acute conditions, patients are exposed to the benefits as well as the potential harm of the medications. Also, as people age, they are more likely to develop one or more chronic illnesses, which will be treated with medications. While appropriate medication can help people live longer, more active lives, these benefits have also been accompanied by increased risks of adverse events, side effects, and errors along the medication process and use continuum.




The Stages of the Medication Use Process Where Medication Errors Can Occur

There are a number of discrete stages along the medication use process continuum where medication errors can occur. SIX of the key stages include prescribing, transcribing, preparing, dispensing, administering, and monitoring.

  • Prescribing: This is when a prescribing healthcare provider chooses the most appropriate medication for a patient’s given clinical situation, taking individual factors into account. The provider also selects the most appropriate administration route, dose, time, and regimen.

  • Transcribing: This is the transfer of information from the provider’s orders to the nursing documentation form or to the pharmacy system (manually or virtually).

  • Preparation: After getting the prescription from the provider, the pharmacist reviews it for accuracy, appropriateness, and any errors before picking and preparing (counting, calculating, mixing, or labeling) the drug.

  • Dispensing: This occurs when the pharmacist delivers the prepared medication to the patient or the ward/unit where the prescription was ordered.

  • Administering: Administering a medication involves giving it to the intended user or to the caregiver for administration to the patient. Administering always includes the need to check for allergies and to make sure that the correct dose of the right medicine is given to the right patient via the right route at the correct time.

  • Monitoring: This involves observing the patient to determine whether the medication is working, being used correctly, and not causing harm.


Conditions and Failures That Contribute to Errors and Potential Patient Harm

There are a number of defenses and safeguards along the medication use process that help prevent errors from occurring. These range from systems approaches (for example, computer alerts when there are drug interactions or duplications, or automated hard stops for potentially dangerous prescribing) to personal expertise to policy and administrative controls.

According to a study by James Reason, professor of psychology at the University of Manchester, each of these defense and safeguard layers will have systematic processes in place to prevent errors from occurring. In reality, however, these layers are more like slices of Swiss cheese, with holes in each slice. The presence of a hole in one layer (or stage) does not usually necessitate a bad outcome. Errors occur when the “holes” in all layers line up to permit a trajectory of accident opportunity, causing potential harm to the patient.

The holes in the medication process stage defenses arise for two reasons: active failures and latent conditions. Nearly all adverse events and medication errors involve a combination of these two sets of factors.


  • Active failures: “These are the unsafe acts committed by people who are in direct contact with the patient or system. They take a variety of forms: slips, lapses, fumbles, mistakes, and procedural violations,” according to Reason.97

  • Latent conditions: These are the inevitable “resident pathogens” within the system that arise from decisions made by people in the system and top level management. Latent conditions have two kinds of adverse effects: (1) They can translate into error- provoking conditions within the workplace (time pressure, understaffing, inadequate equipment, fatigue, inexperience); and (2) they can create long-lasting holes or weaknesses in the defenses (alarms and indicators that go off constantly, complex or unworkable procedures, design deficiencies). Latent conditions can lie dormant within the system for months to years before they combine with an active failure or trigger, creating an accident opportunity.


Impact and Consequences of Unsafe Medication Use and ADEs The concern raised in “To Err Is Human” about the prevalence and impact of ADEs (two out of  every  100  hospitalized  patients)  was just the beginning of our understanding of the potential magnitude of the rates of medication errors. IOM’s 2007 report (“Preventing Medication Errors”) stated that “a hospital patient is subject to at least one medication error per day, with considerable variation in error rates across facilities.”

For More information about Medication Safety, see the information below:

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SAFE Medication Practices Information