Drug and Therapeutics Committees - A Practical Guide
(2003; 155 pages) [French] [Spanish] [Vietnamese] View the PDF document
Table of Contents
View the documentAcronyms and abbreviations
View the documentPreface
Open this folder and view contents1. Introduction
Open this folder and view contents2.Structure and organization of a drug and therapeutics committee
Open this folder and view contents3. Managing the formulary process
Open this folder and view contents4.Assessing new medicines
Close this folder5.Ensuring medicine safety and quality
View the document5.1 The need for ensuring medicine safety and quality
View the document5.2 Monitoring and addressing medication errors
View the document5.3 Monitoring and ensuring medicine quality
View the document5.4 Safety of medicines
View the documentAnnex 5.1 Basic analytical medicine tests
View the documentAnnex 5.2 Examples of adverse drug reaction reporting (ADR) reporting forms
View the documentAnnex 5.3 Naranjo algorithm for assessing the causality of an ADR
Open this folder and view contents6.Tools to investigate the use of medicines
Open this folder and view contents7.Promoting the rational use of medicines
Open this folder and view contents8.Antimicrobials and injections
Open this folder and view contents9. Getting started
View the documentGlossary1
View the documentReferences
View the documentFurther reading
View the documentUseful addresses and websites
View the documentBack cover

5.2 Monitoring and addressing medication errors

A medication error is any preventable event where a dose of medication that is received by a patient differs from what the prescriber has prescribed, or from hospital policy and procedures (AHSP 1999). These errors may result in therapeutic failure and adverse drug reactions as well as wasting resources. It has been estimated that medication errors cause 7000 deaths per year in the USA (Philips and Christenfeld 1998). In another study, 2% of inpatients in two teaching hospitals experienced preventable ADRs increasing the cost of their hospitalization by US$4700 per admission and the length of their stay by 4.6 days (Bates et al. 1997). One of the functions of the DTC is to monitor and report on the occurrence of medication errors in order to ensure that they occur as rarely as as possible. The following are some of the possible errors that can occur either in the prescribing, dispensing or administration processes, and which should be monitored:

• prescribed medication not given

• administration of a drug that was not prescribed

• medicine given to the wrong patient

• wrong medicine or IV fluid administered

• wrong dose or strength given

• wrong dosage form given, for example eye drops instead of ointment

• wrong route of administration

• wrong rate of administration, for example IV infusion

• wrong time or frequency of administration

• medicine given for the wrong duration

• wrong preparation of a dose, for example incorrect dilution of a dose, not shaking a suspension

• incorrect administration technique, for example unsterile injection technique (see section 8.2) or incorrect installation of eye ointment

• medicine given to a patient with a known allergy.

Having a pharmacist or nurse, or another doctor or prescriber, review the prescriptions before the drugs are administered can prevent some of these errors. Whenever an error is identified, it must be documented and the prescriber or nurse administering the medication informed. All errors should be compiled and a report presented monthly. It is important to do this in a non-confrontational manner without mentioning names of the doctor, nurse or pharmacist responsible for the errors. The report should contain information about the number and type of errors, the type of staff reporting each error and the ward or department. The DTC should review all medication errors in order to (1) address individual incidents, and (2) look for patterns and trends in order to address health system, managerial and environmental problems that may be encouraging such errors. Table 5.1 shows a sample report of medication errors from a Zimbabwean hospital.

Common underlying problems that are associated with medication errors, and which the DTC could address, include:

• high staff workload and fatigue

• inexperienced and inadequately trained staff

• poor communication among health-care workers, including poor handwriting and verbal orders

• environmental factors, for example poor lighting, much noise, frequent interruptions

• increased number or quantity of drugs per patient

• frequency and complexity of calculations needed to prescribe, dispense or administer the drug

• large number of formulary medicines and dosage forms (such as injections) that are associated with more errors

• confusing drug nomenclature, packaging or labelling

• lack of effective drug policies and procedures.

Table 5.1 Medication errors report for September 1999 in a Zimbabwean hospital



Brief description





heparin 15000 u/100 ml given instead of 10000 u/100 ml





ofloxacin 200 mg tablet given instead of 400 mg tablet





theophylline 5 mg/kg loading dose given instead of 6 mg/kg
All errors of dose or strength


3 (42.9%)



amoxicillin given 4 times instead of 3 times daily





furosemide prescribed every 4 hours but given every 6 hours





potassium chloride prescribed every 8 hours but charted 1000hrs, 1600hrs and 2100hrs
All errors of time or frequency


3 (42.9%)



chlorpromazine given instead of chlorpropamide
All errors of actual drug


1 (14.2%)


Source: Zimbabwe DTC manual (1999).
Key: A, wrong dose or strength; B, wrong time or frequency; C, wrong drug.

Some ways of preventing medication errors, particularly in hospitals, include:

• establishing a consensus group of physicians, nurses and pharmacists to select best practices

• introducing a punishment-free system to collect and record information about medication errors

• developing written procedures with guidelines and checklists for the administration of intravenous fluids and high-risk drugs such as insulin, heparin and narcotics

• developing standardized times to administer medicines and a policy to do so only when patients are on the wards

• requiring that a patient’s identity be confirmed before administering a drug

• allowing verbal or telephone orders only in an emergency

• requiring legible handwriting and complete spelling of a drug name

• requiring the use of standardized notation

• dose units written in one way only, for example ‘mcg’ not ‘ g’ or ‘g’ not ‘gm’

• use of leading zeros for values less than 1 (0.2 instead of.2) and avoidance of trailing zeros for values more than 1 (2 instead of 2.0)

• requiring that the route of administration and the complete directions (for example ‘daily’ not ‘OD’) be written on all drug orders (prescriptions)

• requiring that prescribers write generic and brand names for medicines with ‘look-alike’ or ‘sound-alike’ names.


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