The 3 Most Common Medication Dispensing Errors and Risks

Academy of Managed Care Pharmacy (AMCP) reports that "the three most common dispensing errors are: dispensing an incorrect medication, dosage strength or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications. Errors caused by drug administration can be made by the health care provider or by the patient themselves."

In the realm of healthcare, ensuring the safe and accurate dispensing of medications is a critical aspect of promoting patient well-being and minimizing potential health risks. However, the prevalence of medication dispensing errors continues to be a pressing concern within the healthcare landscape. These errors, which can occur at various stages of the dispensing process, pose significant challenges for both patients and healthcare providers. Understanding the root causes, potential consequences, and proactive measures to prevent these errors is paramount in upholding the highest standards of patient safety and care. At 7 Day Home Care, we recognize the gravity of this issue and are committed to shedding light on the importance of implementing robust strategies to mitigate the occurrence of medication dispensing errors, thereby fostering a safer and more secure healthcare environment for all.

According to Academy of Managed Care Pharmacy "medication errors are among the most common medical errors, harming at least 1.5 million people every year. The extra medical costs of treating drug-related injuries occurring in hospitals alone are at least to $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs, the report says.1 Medication error morbidity and mortality costs are estimated to run $77 billion dollars per year.2 Patient safety is a major public health concern."

1. Dispensing an incorrect medication, dosage strength, or dosage form can have serious implications for patient health and well-being. The risks associated with such errors, whether initiated by a healthcare professional or a patient, can lead to a range of adverse consequences.

When healthcare professionals dispense the wrong medication, dosage strength, or dosage form, the risks include:

• Adverse drug reactions: The patient may experience harmful side effects or allergic reactions due to the administration of a medication that is not suitable for their condition or medical history.
• Worsening of the underlying health condition: Dispensing the wrong medication or an inappropriate dosage may fail to effectively manage the patient's health condition, leading to its exacerbation or progression.
• Drug interactions: Inaccurate dispensing can lead to potentially dangerous drug interactions if the patient is already taking other medications. This can result in adverse effects and complications that may compromise the patient's health.
• Delayed recovery: Administering the wrong medication or an incorrect dosage can delay the patient's recovery process and prolong the duration of the illness or medical condition.

On the other hand, when patients themselves dispense the wrong medication, dosage strength, or dosage form, the risks include:

• Self-harm: Ingesting the wrong medication or an incorrect dosage can result in harm to oneself, exacerbating existing health issues or creating new complications.
• Masking of symptoms: Taking the wrong medication may mask the symptoms of the actual health condition, leading to a delay in seeking appropriate medical treatment and potentially allowing the underlying condition to worsen.
• Increased health risks: Patients may unknowingly subject themselves to potential health risks by taking medications that interact unfavorably with their current health status or other prescribed medications.
• Compromised treatment efficacy: Inaccurate self-medication can compromise the effectiveness of the prescribed treatment plan, leading to suboptimal health outcomes and prolonged recovery periods.

It is imperative for healthcare professionals to exercise due diligence in the dispensing process, ensuring accuracy and adherence to established protocols. Similarly, patients must adhere to prescribed medication guidelines and seek clarity from healthcare professionals if they have any doubts or concerns. Open communication and patient education play pivotal roles in preventing the risks associated with incorrect medication dispensing, ultimately promoting better health outcomes and patient safety.

    2.   Miscalculating a medication dose can lead to serious health risks and adverse consequences for the patient. Whether the error is made by a healthcare professional or the patient, it can have detrimental effects on the individual's health and well-being. Some of the information and risks associated with miscalculating a medication dose are as follows:

When a healthcare professional miscalculates a medication dose, the risks include:

• Overdose: Administering an excessively high dose of medication can lead to toxicity, causing severe side effects, organ damage, or even life-threatening complications.
• Underdose: Providing a lower-than-prescribed dose may result in the medication's ineffectiveness, leading to inadequate treatment of the patient's medical condition and potential progression of the illness.
• Adverse drug reactions: Miscalculating the dose can increase the likelihood of adverse drug reactions, such as allergic responses, drug interactions, or other unexpected side effects that can jeopardize the patient's health.
• Treatment delays: Incorrect dosing can lead to delays in the patient's recovery process, potentially prolonging the duration of the illness or medical condition.

When patients miscalculate their medication dose, the risks include:

• Self-harm: Taking an incorrect dose, whether too high or too low, can harm the patient's health, potentially leading to severe side effects, complications, or exacerbation of the underlying health condition.
• Treatment inefficacy: Incorrect dosing can compromise the effectiveness of the prescribed treatment plan, rendering the medication less potent or completely ineffective in addressing the patient's health concerns.
• Worsening of symptoms: Miscalculating the dose may exacerbate the patient's symptoms or delay their recovery, leading to increased discomfort and a prolonged healing process.
• Adverse health outcomes: Inaccurate self-dosing can result in unforeseen health complications, including organ damage, allergic reactions, or other severe health risks, depending on the specific medication and the patient's individual health profile.

To prevent these risks, healthcare professionals must adhere to standard dosing guidelines, double-check calculations, and maintain clear communication with patients regarding their prescribed medications. Patients should strictly follow the prescribed dosage instructions, seek clarification from healthcare professionals when needed, and never alter their medication dose without consulting a healthcare provider. Proactive measures and patient education are essential in ensuring the safe and effective use of medications and minimizing the risks associated with miscalculating medication doses.

   3.  Failing to identify medication or drug interactions and contraindications can have serious implications for patient safety and well-being. Again, both healthcare professionals and patients play critical roles in recognizing potential interactions and contraindications, as well as taking appropriate measures to prevent adverse health outcomes. Here is some information and the associated risks of failing to identify medication or drug interactions and contraindications:

When healthcare professionals fail to identify medication or drug interactions and contraindications, the risks include:

• Adverse reactions: Certain combinations of medications can result in adverse reactions, leading to severe side effects, allergic responses, or other unexpected complications that can jeopardize the patient's health.
• Worsening of health conditions: Failing to recognize contraindications or drug interactions can exacerbate the patient's existing health conditions, leading to a worsening of symptoms or the progression of the illness.
• Treatment inefficacy: In the presence of drug interactions or contraindications, the effectiveness of the prescribed treatment plan may be compromised, rendering the medication less potent or completely ineffective in addressing the patient's health concerns.
• Delayed recovery: Overlooking potential drug interactions or contraindications can lead to delays in the patient's recovery process, prolonging the duration of the illness or medical condition.

When patients fail to identify medication or drug interactions and contraindications, the risks include:

• Self-harm: Neglecting to recognize potential interactions or contraindications can result in harmful side effects, complications, or exacerbation of the underlying health condition, leading to self-inflicted harm.
• Masking of symptoms: Certain drug interactions or contraindications may mask the symptoms of the actual health condition, delaying appropriate medical treatment and allowing the underlying condition to worsen over time.
• Increased health risks: Patients may unknowingly subject themselves to potential health risks by combining medications that interact unfavorably with their current health status or other prescribed medications.
• Compromised treatment efficacy: Failing to identify potential drug interactions or contraindications can compromise the effectiveness of the prescribed treatment, leading to suboptimal health outcomes and prolonged recovery periods.

To mitigate these risks, healthcare professionals must conduct thorough patient assessments, consider the patient's medical history and current medication regimen, and stay updated on the latest information regarding potential drug interactions and contraindications. Patients should communicate openly with their healthcare providers, disclose their complete medication history, and seek professional guidance before combining different medications. Proactive measures, including patient education and regular medication reviews, are essential in preventing the risks associated with failing to identify medication or drug interactions and contraindications.

AMCP reports the following list with respect to how some medication dispensing errors may arise:  "preventable errors occur because systems for safely prescribing and ordering medication are not appropriately used.

• A widely recognized cause of error is illegible handwritten prescriptions.
• Errors may result from insufficient or missing information about co-prescribed medications, past dose-response relationships, laboratory values and allergic sensitivities.
• Errors in prescribing can occur when an incorrect drug or dose is selected, or when a regimen is too complex.
• When prescriptions are transmitted orally, sound-alike names may cause error.
• Similarly, drugs with similar-looking names can be incorrectly dispensed when prescriptions are handwritten.
• Errors may occur because a prescription is never transmitted to a pharmacy, or a prescription is never filled by the patient.
• Physician sampling of medications can contribute to medication errors due to the lack of both adequate documentation and drug utilization review."

As a leading provider of both outstanding and affordable in-home care services, including the all important medication reminders, 7 Day Home Care is committed to fostering a safe and secure healthcare environment for our clients in Manhattan, Queens, Brooklyn, Nassau County, and Suffolk County, New York. While every effort has been made to ensure the accuracy and reliability of the information provided in this article, it is important to note that the content is intended for informational purposes only and should not be considered a substitute for professional medical advice or treatment. For personalized guidance and specific healthcare concerns, we strongly urge readers to thoroughly consult with qualified healthcare and medical professionals.

Brian Callahan

7 Day Home Care