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Safe Medication Practices - October 2000

"The informed patient is one of the best safeguards against medication errors" 1

M. Cohen

Today’s patients are more educated, are very interested in knowing and understanding their medications, and are aware that mistakes, although infrequently serious, can happen. Recently, a national survey was carried out in the United States, by the American Society of Health-System Pharmacists, to determine patient’s top concerns upon entering a hospital. Results of the survey revealed that 61% of the respondents were "very concerned" about "being given the wrong medicine".

In responding to patient’s concerns, not only do we, as healthcare providers, need to continuously improve our medication systems, we also need to ensure the patient’s role continues to be developed.

How do We Develop the Patient’s Role in Reducing Medication Errors?

  1. Encourage patients to ask health care personnel about the names and purposes of their medications.

Basic questions to ask about medications in a hospital:

    1. What is the name of the medication?
    2. What is the purpose of the medication?
    3. What is the strength and dose?
    4. How often should I be getting this medication?
    5. What are the possible side effects?
    6. Is this medication replacing any other drug I have been taking?

If the patient is not well enough to ask questions, a family member or friend should feel comfortable in the role of asking questions on the patent’s behalf.

  1. Ensure the patient is kept "in the know" and is well informed.

    Involving the patient and keeping him or her informed every step of the way not only ensures they are a partner, or team member, in their own care, it can have added benefits of increased safety. At BC Children’s Hospital in Vancouver 2, new policy requires that the drug name, patient name and dose of each chemotherapy drug be read aloud by both the doctor and the nurse before it is administered. The intent for reading aloud the label is to provide each other with a "second check" and to increase communication. This change in policy was one among several changes made after an in depth review of an error. Hearing the information, as well as seeing it, can add to the healthcare worker’s checking process.

    Imagine if the nurse could make it part of regular practice to read aloud the drug name at the time of giving medications. Patients would also hear the information at the same time, and would be learning about their medications. They would have opportunity to ask questions about the information they hear. Certainly they would know if the name of the patient on the label is not theirs.

  2. Encourage patients to maintain an up-to date, accurate medication list. Many patients already keep such a list. When patients are preparing for discharge, the list needs to be updated. Medication requirements often change as a result of the hospital stay. Patients can ask assistance with preparing a list from their doctor, nurse and pharmacist.

  3. After discharge, the patient can ask additional questions of the retail pharmacist such as (1) storage of the medication (2) what to do if a dose is missed and (3) what interactions with foods or over-the counter medications to be aware of.

How do we know patients can prevent medication errors?

Listed below are some examples of real-life "near-error" situations:

Patient: "The intravenous is causing a burning sensation in my arm".
This concern prevented the administration of a medication which needed to be further diluted.
    Patient: "Yesterday, I got two different pills, instead of one, at this time of day". 
    This comment prevented an omission of a medication.
    Patient: "The colour of my intravenous solution looks different. It looks lighter". 
    This comment prevented administration of an incorrect dose.
    Patient: "Is it possible my new medication is causing me to feel dizzy". 
    This question resulted in a dosage reduction.

These examples illustrate the value of good listening skills by health care providers. In each of these cases, the value of addressing patient concerns and questions was recognized.

Some patients will be reluctant to ask questions. They do not want to be seen as "troublesome". As a result they hesitate to ask questions, even when they think something may not be right. There can be an attitude of "Who am I to question the doctor ". Such a situation (or culture, or climate) is called a "disconnect’ in the system and can increase the possibility of medication errors. Fortunately, this attitude is changing 3. Patients of today, and even more so, patients of tomorrow, will be more willing to ask questions and will be more involved in their healthcare.

Patients are changing and this will change how we work. Because informed patients can prevent medication errors and because they can serve as an "extra check" in the medication system, healthcare workers of today and tomorrow will encourage patients to take an active role and will create a climate of encouraging questions.

In summary, patients can play an important role in their medication therapy and error prevention by asking questions of health care providers. Patients also provide valuable information. Any concerns raised, warrant investigation. As healthcare providers we need to be sure we are always listening and always providing ongoing information to patients.

We all want the same thing – safe medication systems. Working as team, and involving patients in their care, will ensure this common goal.

Sylvia Hyland,

Pharmacy Site Operations Manager, Toronto Western Hospital, University Health Network.
Institute for Safe Medication Practices - Canada, Advisor to the Board.


  1. Cohen, M. R..editor, Medication Errors. American Pharmaceutical Association. Washington. 1999. Hospital Pharmacy Practice. January/February 1998. Vol 6 No.1
  2. Booth, B. A M News staff. Feb 28, 2000 cited in

By Professor John Senders

The nature and source of human error

Human error can happen in everything we do. This has been recognized for more than a thousand years. Naturally enough, the general public gets nervous when they read about the possibility of medical error.

How is error defined?

The dictionaries are unhelpful. Error is defined in terms of other words which also mean error. I find it more useful to define error in terms of whether they are "execution" errors or "intention" errors, but this view is not agreed to by all experts. In my view, if a correct intention is followed by an unintended action, then an execution error has occurred - you intended to brake at the red light but stepped on the gas instead. Similarly, if an incorrect intention was formed (and properly executed), then an intention error has occurred - you deliberately reached for the salt instead of the pepper. Some experts call these two kinds of errors "slips" and "mistakes" respectively. Whatever the errors are called, the simple analysis tells us we have to be planning to do something in order to plan it wrong or do it wrong.

Can we predict when errors will occur?

All the evidence says that it is impossible to say even approximately, let alone exactly, when an error will be made. The best we can do is to predict that error rates will increase or decrease under certain conditions. Thus, it is easy to predict that the probability of writing 1984 shortly after New Year"s Day, 1985, is high. Exactly when each of the 1984-1985 errors will occur cannot be predicted. When errors happen they are always unexpected.

Can we predict what kinds of errors will occur?

We can do better on this question. The writing of the wrong year is quite predictable. We tend to do things by habit as we become more efficient and automated. What will be done wrong has to be chosen from the things that are available to be done. For example, if concentrated potassium chloride is not available, then we cannot improperly substitute it for another drug. Implementing changes in systems can prevent predicted errors from occurring.

What causes human error?

Many errors may be considered to be uncaused, or at the most indeterminate, arising from random neural events (endogenous errors). Others (the exogenous errors) appear to arise from poor design of packages and labels, and improper choice of the names of pharmaceuticals. The former, the errors that come from unknown events within us, are difficult to eliminate. The key to prevention of patient injury is to have adequate error-detection "checks" in the system. The latter, the errors that come from confusing packaging, naming and labelling, are easier to predict and design around.

In summary, we can define error in terms of intention; we cannot predict when an error will occur; we can predict when the chance of an error will increase or decrease; we can make good estimates of what kind of error might occur; and we have little or no idea of why we make errors that are not traceable to the design of things.

Although we may not always be able to determine exact causes of human errors, there is a great deal of information about factors or situations that increase the probability of error. These factors are of three different kinds: personal factors like fatigue, and poor vision; situational factors like poor lighting and improper work scheduling; and equipment factors like confusing names and illegible printing. Efforts to reduce the probability of patient injury need to be aimed at these three categories.

John Senders is on the board of directors of the Institute for Safe Medication Practices Canada. Safe Medication Practices is a regular column in Hospital News.