Medication Errors

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See also: Medication errors and CPOE


Understanding the nature and causes of Medication Errors (ME) is paramount to clinical care as well as the implementation, maintenance and improvement of Computerized Physician Order Entry (CPOE), Medical Decision Support System (MDSS), and Clinical Decision Support (CDS). This article contains a brief overview of the medication management process steps and attributes of CPOE that may contribute to ME. This article provides links to already-existing Clinfowiki pages related to ME’s, and organizes them based on the step of the medication management process. The step of the process is vital for developing intervention strategies to reduce ME’s within any given information system.

Medication Errors are distinguishable from Adverse Drug Events in that an ADE is defined as “an injury resulting from medical intervention related to a drug.” In contrast, a Medication Error (ME), as defined by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)8:

"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 health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use."

Classification of Medication Errors

Medication Errors can be classified based on the extent to which the error may have caused harm to the consumer, and can be classified based on the nature of the error. The NCC MERP is a collaborative group of agencies in healthcare, founded in the 1990’s, which supports the efforts to reduce medication errors through education, reporting and prevention, in order to maximize patient safety. The NCC MERP has developed a well-known chart to categorize medication errors.


Medication errors can also be categorized based on the type of error and can occur at any step of the medication management process. Types of medication errors include (but are not limited to), wrong medication, wrong dose of medication, wrong route of administration, administration to the wrong patient, transcription error, failure to administer medication, and administration of medication despite monitoring that would indicate withholding medication.

Medication management process

Steps of Medication Management over the course of patient care, extending from the order created by the prescriber, to the patient/consumer 1

    1. Prescribe – medication order initiated
      a. Role: Prescriber (utilizing clinical guidelines, MDSS and CDS tools).
      b. High variability of medication errors (3-79%).
      c. Clinfowiki links:
        - Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit
        - Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review
        - E-prescribing
        - The Influence that Electronic Prescribing has on Medication Errors and Preventable Adverse Drug Events: an Interrupted Time-Series Study
        - Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE)

    2. Transcribe – medication order read and verified

      a. Role: Nursing, Pharmacy (primary) nursing and/or pharmacy
      b. Pharmacists were able to intercept 70% of all physician order errors

    3. Dispense/Deliver – medication transferred from manufacturer package to consumer

      a. Role: Pharmacy
      b. Studied extensively in the pharmacy literature; pharmacy errors 4-42%
      c. Clinfowiki links:
        - Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy
        - Addition of electronic prescription transmission to computerized prescriber order entry: Effect on dispensing errors in community pharmacies.

    4. Administer – medication given to consumer, medication enters body

      a. Role: Nursing (or nursing delegates), or consumer
      b. Studied extensively in nursing literature, nursing spends up to 40% of their time engaging in medication administration activities
      c. Clinfowiki link:
        - Medication errors

    5. Monitor/Report

      a. Roles: Prescriber, pharmacy, nursing, medical assistants
      b. Examples: warfarin/PT/INR, clozapine REMS, state prescription monitoring systems, chemotherapy, medication errors

Medication errors and Computerized Physician Order Entry

Computerized Physician Order Entry (CPOE) has been shown to decrease medication errors, with extensive research focus on inpatient settings. 2,3,4,5,6 Implementation of CPOE in itself impacts medication errors, as well as integrating CPOE with MDSS or CDS. When taking multiple systematic reviews into consideration, it is notable that there is variability in the overall reported prevalence of CPOE-related medication errors (6.1-77.7% in one study)4, the definition of a medication error,4,7,8 as well as the outcome measure reported (85% reduction in medication prescribing error rates in ICU setting in one study).3

Clinfowiki links

    - Medication errors: prevention using information technology systems
    - Interventions to reduce medication errors in pediatric intensive care
    - Can Utilizing a Computerized Provider Order Entry (CPOE) System Prevent Hospital Medical Errors and Adverse Drug Events?
    - Criteria for assessing high-priority drug-drug interactions for clinical decision support in electronic health records
    - Risk factors for adverse drug events

Attributes of CPOE that can facilitate medications errors 9,10,11

Navigation and workflow processes
  • Display – challenges with the visual display on the monitor: incomplete medication list visible on one screen, different types of orders divided between screens, not able to readily identify current/active patient
  • Drop-down menus” – drop-downs are common in single- and multi-select data entry sections in CPOE navigation; choosing an entry immediately above or below the target choice can lead to complete change in the order itself
  • Reconciliation and discontinuation processes – lack of clarity in the process to change/modify or discontinue medications, or extensive reconciliation process could lead to discontinued medication continuing to be prescribed (or medication not continued when meant to)
  • “Wording” – the semantics used in the information system may have built-in assumptions
  • Inflexible or excessive processes/workflows that lead users to create “workarounds” – workarounds include copy/paste, alternative workflows that may lead to error
  • User work processes – batch data entry, time delay for data entry, log-in processes
  • Reliance on CPOE for dosing guidance – there can be inappropriate trust in the built-in dosing guidance that, while relevant in most situations, may not reflect nuances in the clinical situation
  • Auto-populating fields – similar to reliance on CPOE for dosing guidance, there can be oversight of the fields that auto-populate, that, while in most cases may be accurate, may lead to choosing the wrong medication or wrong dose for a particular clinical situation
  • Default settings – leading to incorrect dose, incorrect medication, or the prepopulated information for a particular medication may not be accurate to the patient needs or clinical guideline; the default settings may even neglect to consider monitoring requirements (vitals, labs, etc)

    While there is clear evidence that CPOE reduces medication errors, there remains, as noted above, numerous attributes of CPOE that merit ongoing investigation and improvement to continue to enhance patient safety. It will also be imperative to move toward consistency in definitions and attributes, to support robust systematic reviews.


    1.Hughes RG, Blegen MA. Medication Administration Safety. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 37. Available from: Accessed: October 26, 2020.

    2.Bates DW, Cohen M, Leape LL, Overhage M, Shabot MM, Sheridan T. Reducing the Frequency of Errors in Medicine Using Information Technology. J Am Med Inform Assoc. July 2001; 8(4): 299–308.

    3.Prgomet M, Li L, Niazkhani Z, Georgiou A, Westbrook JI. Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis. J Am Med Inform Assoc. Mar 2017;24(2):413-422.

    4.Korb-Savoldelli, Boussadi A, Durieux P, Sabatier B. Prevalence of computerized physician order entry systems–related medication prescription errors: A systematic review. Int J Med Inform. Mar 2018; 111: 112-122.

    5.Abraham J, Kitsiou S, Meng A, Burton S, Vatani H, Kannampallil T. Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews. BMJ Qual Saf. Oct 2020;29(10):1-2.

    6.Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.

    7.World Health Organization. Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO. Accessed:;jsessionid=008A8C67F2C3DC983E24BD9B672321AA?sequence=1 October 26, 2020.

    8.National Coordinating Council for Medication Error Reporting and Prevention. Accessed October 26, 2020

    9.Brown CL, Mulcaster HL, Triffitt KL, Sittig DF, Ash JS, Reygate K, Husband AK, Bates DW, Slight SP. A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care. J Am Med Inform Assoc. Mar 2017; 24(2): 432-440.

    10.Jung SY, Hwang H, Lee K, Lee HY, Kim E, Kim M, Cho IY. Barriers and Facilitators to Implementation of Medication Decision Support Systems in Electronic Medical Records: Mixed Methods Approach Based on Structural Equation Modeling and Qualitative Analysis. JMIR Med Inform. 2020; 8(7): e18758.

    11.Koppel R, Metlay JP, Cohen A, et al. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. JAMA. 2005;293(10):1197–1203.

    Submitted by Jessica O'Neil, DO