Deeper dive

Preventing medication errors: a global challenge

Medication errors are a leading cause of avoidable harm in healthcare, affecting millions of people worldwide each year. These mistakes not only hurt patients but also put a significant financial strain on healthcare systems. By understanding the different types of errors and finding effective ways to prevent them, medication safety can be improved for everyone.

The scope of the problem

  • 1 in 20Medication errors harm 1 out of every 20 patients in healthcare.
  • GlobeThe global cost of medication errors is around $42 billion annually.
  • 50%50% of all avoidable harm in healthcare is caused by medications.

What is a medication error?

“A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.”

– National Coordinating Council for Medication Error Reporting and Prevention

The critical stages for medication errors

Critical stages for medication errors

Medication errors can happen at any point in the medication process, from prescribing to monitoring. WHO has found that at least 1 in 20 patients (5%) experience preventable medication-related harm globally. Understanding the critical stages where errors occur can help us implement checks, processes, and guidelines to prevent avoidable harm.

Prescribing

Errors occur when the wrong medication is prescribed, or when the correct medication is prescribed with the wrong dose, route, frequency, or duration.

Dispensing

Mistakes can happen during the preparation and dispensing of medications, such as providing the wrong medication or incorrect dosage.

Administering

Errors can occur when the medication is given to the patient, such as administering it at the wrong time or via the wrong route.

Storage

Medications can become less effective or unsafe if they are not stored correctly. This includes keeping them at the right temperature.

Monitoring

Patients risk being harmed if adverse effects are not detected, or necessary adjustments to the treatment are not made.

Illustrated collage highlighting stages in the medication process where medication errors can occur. In the first image, a man receives a prescription from his doctor. The second image shows a woman picking up her prescribed medication at a pharmacy. The third image depicts a woman placing her medication in the refrigerator for storage. The final image shows a man clutching his stomach in discomfort. A medicine container is visible in the background.

Those most at risk

Some of us are more vulnerable to medication errors, particularly if we are elderly, children, or pregnant. By understanding and recognising the challenges these groups face, we can come up with better ways to protect them.

Child patients

  • Lack of paediatric guidelines: Many medications do not have specific dosing guidelines for children, making it difficult to determine the correct dose.
  • Dispensing challenges: Medications prescribed for children often require precise calculations based on age, size, and weight, increasing the risk of dosing errors.
  • Administration errors: Mistakes can occur in how medications are administered, such as inaccurately measuring liquid doses or ensuring children take their full dose.
Illustration of a child covering his mouth with his hand as his father attempts to give him medication.
Illustration of an elderly man with his medications. He is holding a pill in his hand, seemingly trying to identify what medication it is.

Elderly patients

  • Polypharmacy: Taking multiple medications increases the risk of drug interactions and side effects.
  • Physical impairment: Elderly patients may have difficulties taking their medicines, such as swallowing tablets, opening packaging, or reading instructions.
  • Adherence to complicated medication regimens: Complex medication schedules can lead to missed or double doses.

Pregnant patients

  • Harm to the unborn baby: Some medications can cause birth defects or developmental issues in the foetus.
  • Physical changes: Changes in the body during pregnancy can affect how medications are processed, leading to incorrect dosages.
  • Mixing medications: Taking prenatal vitamins, supplements, and prescribed medications together can cause unexpected reactions.
Illustration of a pregnant woman reading the label on a medicinal product.

Medication error reporting

Medication errors happen at different stages of treatment. Between December 2019 and December 2024, the number of medication error reports in VigiBase, the WHO global database of adverse event reports for medicines and vaccines, more than doubled – from 1.2 million to 2.6 million.

Based on the most reported errors in VigiBase, these are the areas where mistakes most often occur, listed in order of frequency:

  1. Administering
  2. Storage
  3. Dispensing
  4. Prescribing
  5. Monitoring

While reporting varies across countries, these insights can help you identify key areas to monitor in your own healthcare setting.

As of 31 December 2024, there were 2,565,978 medication errors reports in VigiBase. Medication errors most frequently occurred during administering (52.1%), storage (5.8%), dispensing (3.1%), prescribing (2.5%), and monitoring (0.5%).

Administration errors and the 5 rights of medication use

Global adverse event reporting suggests that administration errors are the most common area of concern. The five rights of medication use – right patient, right drug, right time, right dose, and right route – are essential for minimising administration errors. Following these rights can greatly reduce the risk of harm.

The 5 Rs

  1. Right patient: Is this the correct patient for this medication?
  2. Right medication: Is this the appropriate medication for the patient’s condition?
  3. Right dose: Is this the correct dose for the patient?
  4. Right time: Is this the appropriate time to administer the medication?
  5. Right route: Is this the correct route for administering the medication (e.g. oral, intravenous)?

Illustration of a medicine bottle and a dosing spoon.

Dispensing and preparation good practice

Reporting patterns also highlight that errors at the dispensing and preparation stages are areas of concern that shouldn’t be overlooked. By asking the right questions and following good practices, we can see to it that medications are prepared and dispensed safely. Key questions include:

  • Labelling: Are the medicines correctly labelled with the patient’s name and dosage instructions?
  • Storage: Are there any special storage requirements for the medicines (e.g. refrigeration)
  • Dosage: Is the dosage appropriate for the patient?
  • Interactions: Could these medicines interact with other medications?
  • Instructions: Are there clear guidelines for the patient on how to take the medicines?

Illustration of a medicine bottle being dispensed from one hand to another.

Encouraging reporting of medication errors

Reporting medication errors should focus on learning and prevention, not on assigning blame. Creating a safe reporting culture, protecting anonymity, and recognising those who actively report can significantly improve medication safety. While medication errors are often reported to patient safety organisations, pharmacovigilance centres can fill this gap where no such system exists. To encourage reporting:

✓ Protect anonymity where possible to encourage open reporting.

✓ Recognise and reward those that actively report and improve medication safety.

✓ Make it easy for patients, carers, and healthcare professionals to report medication errors.

Illustration of a magnifying glass.

Problematic medication groups

Monitoring is vital to preventing medication errors. Double-checking dosages and patient instructions can significantly reduce the risk of mistakes. Here are some of the most well-known groups of medications where errors can have serious consequences:

  • Blood thinners: These medications are crucial for preventing heart attacks, blood clots, and strokes but require careful monitoring to avoid serious complications like bleeding.
  • Insulin and other diabetes medications: Managing blood sugar levels is critical for diabetes patients, and errors in dosing can lead to severe hypoglycaemia (low blood sugar) or hyperglycaemia (high blood sugar).
  • Non-steroidal anti-inflammatory drugs (NSAIDs): Commonly used for pain and inflammation, these medications can cause gastrointestinal issues and other complications if not used correctly.
Illustration of a vaccine syringe. Illustration of an inhaler.Illustration of three supplements. Illustration of a stethoscope.

Beyond medicines: Expanding the definition of medication errors

Medication errors aren’t limited to just medicines. They can occur in these areas as well:

  • Vaccines: Errors in the storage, handling, or administration of vaccines.
  • Medical devices: Errors related to the use of devices like infusion pumps, insulin pens, or inhalers.
  • Supplements: Issues arising from the use of dietary supplements, including interactions with prescribed medications.
  • Diagnostics: Mistakes in diagnostic processes, like misinterpreting test results, which can lead to incorrect treatment plans.