It's important to define exactly what a medication error is and what a medication error isn't. This allows medication errors to be identified by healthcare providers, patients, administrators, and national organizations that track errors, such as ISMP. Once a medication error is identified, strategies can be developed to prevent it from happening again.

E-prescribing helps to reduce some types of prescribing errors. Prior to electronic prescribing, one pediatric ambulatory clinic found 77.4% of prescriptions contained at least one error compared with 4.8% after the institution of electronic prescribing. Before electronic prescribing, the most common errors were attributed to missing essential information (73.3%) or illegibility (12.3%). After the start of electronic prescribing, the rate of missing information declined to 1.4% and illegibility was eliminated [22].

Suffixes at the end of drug names such as CD, SR, and XL can increase the risk of errors. There is no standard meaning to suffixes, and the suffixes don't tell you how fast the medication releases or how often it is dosed. Errors that result from the use of suffixes may happen because of confusion about the suffix, not knowing what the suffix means, and lack of standardized meanings across suffixes. This can lead to product mix-ups, prescriptions written with incorrect dosing intervals or frequencies, omission of a suffix, incorrect suffix, etc. There are recommendations that promote the safe use of suffixes. Safety recommendations regarding suffixes include [42]:

There's a lot that can be done to prevent mix-ups with look-alike/sound-alike drug names. Make sure that prescriptions are written clearly and avoid abbreviations. Include both brand and generic names to provide additional clarification. Repeat drug names back to the prescriber when taking a verbal order. It's also helpful if prescribers make sure patients are aware of the reason a medication has been prescribed and also include the indication for use on the prescription. For instance, if you receive a prescription for atorvastatin with a sig that says "1TPOHS for cholesterol," you should type up the directions as, "Take 1 tablet by mouth at bedtime for cholesterol." Including the indication will remind the patient what the medication is for, which can be especially important when taking multiple meds. Also think of this as another safety check in the dispensing process. For example, digoxin, a heart medication, can sound similar to levothyroxine, a thyroid medication. So an Rx for digoxin with the sig, "Take 1 tablet by mouth daily for thyroid" is a red flag that something is off.

When discussing an OTC product, specify ingredient instead of brand name to prevent confusion. Ask patients about their intended use of OTC products. Pharmacies can stock OTC products by therapeutic category and use shelf alerts to warn customers of product changes.

Tell patients who travel abroad to carry enough of their meds and a list of their drugs by BOTH generic and brand name. Warn patients who are getting drugs abroad to beware. Although medications may seem less expensive, they may not be getting the intended medication. To find out the ingredients of a foreign drug, check with a drug information center (some colleges or pharmacy have one) or call 800-222-1222 to connect to your regional poison control center.

When traveling with medications, patients should be careful not to expose them to extreme temperatures (e.g., in checked baggage or the glove compartment of a car). Having medications in their original labeled prescription containers helps to identify them during security checks and ensures relevant information is readily available if needed.

The key is knowing which alerts are important and which are not. Discontinued drugs cause many alerts, but most aren't serious. But be aware of medications that have long durations of action as their effects can last after discontinuation. Interactions with amiodarone, fluoxetine, and monoamine oxidase inhibitors (MAOIs; e.g., phenelzine, tranylcypromine) can occur for two weeks or longer after the med is stopped. Be careful when cytochrome P450 (CYP) enzyme inhibitors or inducers are discontinued. These CYP enzyme inhibitors or inducers can increase or decrease the activity of some drugs (i.e., substrates). Any substrate that is continued after the discontinuation of CYP enzyme inhibitors or inducers may need a dose adjustment.

Continue to pay attention to the "big" drug interactions:

Ineffective communication is a frequently cited cause of serious patient harm. Verbal prescription orders are not recommended, and it is suggested that they be reserved for urgent situations when written or electronic prescribing is not practical [56]. In the hospital setting, many institutions have created policies to prohibit any verbal orders. In pharmacies, the "verbal order read-back" is essential for all phone orders, verbal orders, and test results that must be taken verbally. This practice helps improve the effectiveness of communication, ensuring that important information is relayed in an accurate, complete, and unambiguous manner [57].

Verbal order read-back has been a National Patient Safety Goal in prior years and is a required practice of some healthcare organizations. Order read-back requires that the recipient first write down the complete order or enter the information into the computer system. The recipient of the information then reads back the order or test result to the individual who gave the order. The recipient must seek and receive confirmation from the individual who gave the order or test result that the information is correct [57].

Use a "teach back" approach. Have patients tell you how and why they are taking their meds. Tailoring drug regimens to the patient's lifestyle helps. For example, check for less expensive generics, meds with fewer doses, or a different side effect profile. When provided, put the diagnosis on the Rx label (this is required if the indication is included as part of the Rx sig), encourage use of a pillbox, give private counseling, and use refill reminder programs. Give patients positive feedback on progress, and encourage them to monitor their blood pressure, blood glucose, etc. Ask open ended questions, such as "What problems have you had with your medications?"

ISMP maintains a list of drugs and drug classes which have the highest risk of causing devastating consequences to patients if used inappropriately. These medications may need to have special safeguards in place, such as double checks, to reduce the risk of errors. Many pharmacies and institutions create their own list, usually based on the ISMP list plus any of their own near misses and reported errors. Lists of high-alert meds may include, but are not limited to [62,63]:

Be aware of best practices to prevent dispensing errors. Adjust your practice so these activities are second nature; make them a habit when you are dispensing prescriptions [12]:

Inaccuracies don't just occur with hospital admissions. It has been found that up to 76% of patients' discharge summaries may include errors [76]. These types of medication errors can be reduced by 70% when pharmacists evaluate medications at admission, transfer, and discharge [76]. On discharge, watch for medications that may be duplicates in therapy. As previously mentioned, patients may have been switched from a home medication to a formulary medication on admission. An error can occur if upon discharge, a prescription is given for both the original home med plus the hospital med. For example, a hospital may stock only one proton pump inhibitor (PPI; e.g., lansoprazole, pantoprazole). If a patient takes lansoprazole at home, they may be switched to pantoprazole on admission if that is the formulary PPI. In this example, it's important to make sure that this patient does not get prescriptions for both lansoprazole and pantoprazole on discharge. Any aspect of medication use that is unclear, confusing, or contradictory should be addressed and information uncovered until the issue is resolved.

The first step in dealing with a medication error is to help the patient [77]. This is the right thing to do. Get the details of the situation by asking the patient important questions, such as why they think an error occurred, whether the medication was taken, how much of the medication was taken, and how they are feeling. Pharmacists should contact the patient's other providers to explain the situation and discuss the best course of action. Pharmacists should try to speak with each provider directly, providing patient details or status, facts about the situation, and what has been done so far.

One caveat is to make sure error reports are written as separate quality assurance documents and are not inserted as a part of the patient drug profile or medical record. This is important from a legal perspective. If an error report is included as part of a patient drug profile, it becomes a part of the patient's medical record. Medical records can be subpoenaed by a court. In most instances, separately written error reports are provided with some protection under the law. This may make it more comfortable for an organization to record errors in the hopes of improving quality assurance without fear of having the documentation used against the organization in a legal matter. Again, error records are meant to be used as learning tools, not punishment.

Failure mode and effects analysis (FMEA) is another process that can be used for examining medication errors. FMEA is a proactive process, rather than a reactive one; it differs from root cause analysis in that it can be used before an error happens, to identify points of potential failure and what the effects would be. Failure mode and effects analysis provides an opportunity to prevent errors with potentially significant consequences, or to minimize their consequences. Like root cause analysis, failure mode and effects analysis requires multidisciplinary resources [12].