What Physicians Should Do When They Make a Medication Error

Physicians, like all people, are not immune to human error. Medical errors can occur at any point during patient care, including prescribing, transcribing, dispensing, and monitoring medication. A StatPearls article noted that between 7,000 and 9,000 people in the United States die annually due to medication errors, with cumulative costs adding to more than $40 billion. Not only do these errors impact patient health, but they also carry a host of heavy psychological and physical costs.

Victims of medical error may develop a sense of mistrust both for their physicians and for the healthcare system in its entirety. Given the wide range of medications available, prescription errors are common. The StatPearls article notes that prescription errors account for nearly half of all medication-error-induced patient injuries. This can encompass everything from prescribing the incorrect medication to indicating the incorrect dose or frequency.

Addressing Error-Prone Areas of Medication Prescription and Use

The medical field is characterized by an unfortunate culture of blame in which medical errors often lead to fines, licensure risks, and litigation, as well as peer-shaming. Nonetheless, physicians have an ethical duty to immediately report medical errors. The Association of Managed Care Pharmacy (AMCP) asserts that physicians should not have to feel uneasy about either committing or reporting an error for fear of subjection to punitive action, suggesting that the healthcare community should rather concentrate on addressing error-prone areas of medication prescription and use in an effort to achieve safer and more reliable outcomes. In other words, the healthcare community should ask why certain errors seem prone to recurring within the existing system and how the system can be changed to prevent future occurrences.

Nonetheless, the Association of American Medical Colleges (AAMC) suggests that physicians offer up complete disclosure when they’ve had the misfortune of committing a medication error. This includes complete explanations to the patient and family and timely reporting and evaluation of any negative consequences. The AAMC also advocates that any clinicians involved in the error receive emotional support. According to the AAMC, the aforementioned measures can spare hospitals, patients, and families years of arduous litigation.

According to Naveed Saleh, MD, MS, it would behoove physicians to adopt strategies that may help to avoid ever erring from the outset. First and foremost, physicians should tackle every prescription with the utmost care. Other recommendations include avoiding misreads and misinterpretations by employing electronic prescriptions and not using abbreviations, in an effort to sidestep handwriting legibility issues. Dr. Saleh also suggests noting precise dosages, specifying treatment duration, and supplying clear instructions.