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Medication Administration Errors and
Community Practice

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Healthcare providers have long been aware that medication errors are all too common. The 1999 Institute of Medicine (IOM) report, “To err is human”, highlighted the issue of medical errors in general, creating a sense of urgency that mobilized the healthcare professions to begin critically evaluating the safety of healthcare - including medication use. To gain some perspec-tive on the magnitude of the problem, consider that more than 3.7 billion prescriptions were filled in U.S. community pharmacies in 2010. A national observational study of 50 community pharmacies found a 1.7% error rate in dispensing. That translates to an annual 62 million dispensing errors – and this does not include errors that occur at other steps in the medication use process. In addition to dispensing, there are at least 5 other components of the medication use process where errors may occur: manufacturing, prescribing, transcribing (data entry), administering (including self-administering), and monitoring.

A medication error is any event that results, or could potentially result, in inappropriate medication use. It can be either an act of commission (e.g., giving/taking an inappropriate medica-tion or dose) or an act of omission (e.g., failure to give/take an appropriate medication). A medication error may or may not have an adverse effect on the patient, often referred to as an “adverse drug event” (ADE). An ADE is any harmful or undesirable event related to medication use. ADEs may be either preventable (caused by medication errors) or nonpreventable (occurring during appropriate medication use; for example, patients may not take them correctly, or may not take them at all. These are errors of administration – or, more specifically, of self-administration. (By this definition, taking an erroneously prescribed or dispensed drug, or accurately following wrong instructions, would not be considered an administration error.) Because self-administration errors occur outside healthcare settings, they have an increased likelihood of going unrecognized. One potentially serious self-administration error is unintentional overdose. In 2004-2005, one third of the estimated visits to U.S. emergency departments (ED) due to ADEs were attributed to unintentional overdose. More than half of the hospitalizations resulting from these ED visits were due to unintentional overdose.

This article focuses primarily on self-administration errors and the role of the community healthcare provider in preventing them. In addition, medication errors that occur during transitions in care (in particular, hospital discharge to home) will be discussed.


Publication Date: 08/18/2012
Expiration Date: 09/01/2015
CE Credit: 1.5 (0.15 CEU)
Type of Activity: Knowledge-based

This program was developed by The Rx Consultant and published by Continuing Education Network, Inc. The Rx Consultant accepts no advertising or financial support from the pharmaceutical industry and is funded solely by the purchase of programs. The Rx Consultant is dedicated to providing unbiased, balanced information to health care practitioners.

Programs developed by The Rx Consultant are written by health care providers with expertise in the topic area, peer-reviewed, extensively edited, and fact-checked. This development process was created to insure that every program presents information that is current, accurate, relevant to "real world" health care providers, and written in an easy reading, "plain English" style.


Kyle E. Hultgren, Pharm.D.

Disclosure Statement

Dr. Hultgren reports no financial or personal relationship with any commercial interest producing, marketing, reselling, or distributing a product or service that appears in this issue.

Target Audience

This accredited program is targeted to pharmacists and nurses.

Goals & Objectives

At the conclusion of this program, participants will be able to:

  • Define the terms “medication error” and "adverse drug event." Name 6 steps in the medication use process where errors may occur.

  • Discuss 3 factors that commonly contribute to self-administration errors.

  • List 3 patient groups that may benefit from targeted counseling.

  • Initiate dialogue with patients and assess their understanding of how to use their medications.

Accreditation Statements

The Rx Consultant is a publication of Continuing Education Network, Inc.

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Continuing Education Network, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education as a provider of continuing pharmacy education.

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Continuing Education Network is approved by the California Board of Registered Nursing, Provider Number CEP 13118. Programs approved by CA BRN are accepted by most State Boards of Nursing.

ACPE Universal Activity Number: 0428-0000-12-008-H05-P

Exam & Credit Statement Procedures

Upon successful completion of this program and the post test (70%), 1.5 hours of continuing education credit will be awarded. To receive credit and your exam score, please complete the exam questions and program evaluation.

Editorial and Review Board

Chief Editor and CE Administrator

Terry M. Baker, PharmD

Managing Editor

Tracy Farnen, PharmD

Associate Editors

James Chan, PharmD, PhD
Pharmacy Quality and Outcomes Coordinator
Kaiser Permanente
Oakland, CA

Associate Clinical Professor
School of Pharmacy
University of California San Francisco
San Francisco, CA

Richard Ron Finley, B.S. Pharm.,R.Ph.
Clinical Pharmacist (volunteer faculty)
University of California, San Francisco (UCSF) Memory and Aging Center
Lecturer (Emeritus) UCSF, Department of Clinical Pharmacy
Health Sciences Clinical Professor, UCSF School of Pharmacy
San Francisco, CA

Consultant Pharmacist
Ray Dolby Brain Health Center, Sutter Health/CPMC
San Francisco, CA

Consult Pharmacist Aging and Adult Health Services
San Francisco Health Department
San Francisco, CA

Julio R. Lopez, PharmD, FCSHP
Chief of Pharmacy Service
VA Northern California Health Care System

Adjunct Clinical Professor
College of Pharmacy
Touro University
Vallejo, CA

Assistant Clinical Professor
School of Pharmacy
University of California, San Francisco
San Francisco, CA Adjunct Professor
Thomas J. Long School of Pharmacy
University of the Pacific
Stockton, CA

Visiting Associate Professor and Lecturer
Nursing School
Samuel Merritt University
Oakland, CA

Pamela Mausner, MD

Helen Berlie, Pharm.D. CDE, BCACP
Clinical Assistant Professor, Pharmacy Practice
Wayne State University
Detroit, MI

Ambulatory Care Specialist - Diabetes
Health Centers Detroit Medical Group
Detroit, MI

Senior Editorial Advisor

Gerard Hatheway, PharmD, PhD

Editorial Advisors

Belinda M. Danielson, RPh
Christopher M. DeSoto, PharmD
Angie S. Graham, PharmD
Cynthia Chan Huang, PharmD, MBA
Fred Plageman, PharmD

Editorial Advisor and Clinical Practice Consultant for Nurse Practitioners

Emily K.
Meuleman, RN, C, MS

About the Rx Consultant

The Rx Consultant is a monthly publication dedicated to providing health care professionals with the information they need to educate patients about drugs and manage drug therapy. The reader is responsible for confirming the information presented here and interpreting it in relation to each patient's specific situation before utilizing the information.

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