A Comprehensive Review of Medication Errors in Modern Healthcare

  • Zeenath Unnissa Department of Pharmacy Practice, Deccan School of Pharmacy, Dar-us-salam, Hyderabad - 500001, Telangana, India
  • Maher Unnisa Deccan School of Pharmacy, Dar-us-Salam, Hyderabad - 500001, Telangana, India
  • Shayesta Khan Deccan School of Pharmacy, Dar-us-Salam, Hyderabad - 500001, Telangana, India


Medication errors are regarded as a significant contributor to the morbidity and mortality rates among patients. These errors encompass any mistake made during the prescription, dispensing, administration, or consumption of medication, as well as the monitoring of therapy. Such errors often stem from factors such as insufficient knowledge, limited staff and resources, issues with medication naming and labeling, and inadequate communication among patients, physicians, and pharmacists. Nonetheless, it is crucial to detect these errors, as shortcomings in healthcare systems can lead to seemingly minor mistakes like misuse and abuse, which may ultimately result in more serious errors. The act of reporting a medication error holds great importance in enhancing the quality of life for patients and reducing the financial burden of re-hospitalization. The primary responsibility of a clinical pharmacist is to identify and assess medication errors with the aim of enhancing patient safety and therapeutic results. By closely monitoring the drug therapy administered to patients in a hospital setting and promptly informing healthcare providers of any inconsistencies discovered, the likelihood of medication errors occurring in hospitalized patients can be minimized.

Keywords: Medication error, misuse, patient safety, quality of life

Keywords: Medication error, misuse, patient safety, quality of life


Download data is not yet available.

Author Biographies

Zeenath Unnissa, Department of Pharmacy Practice, Deccan School of Pharmacy, Dar-us-salam, Hyderabad - 500001, Telangana, India

Department of Pharmacy Practice, Deccan School of Pharmacy, Dar-us-salam, Hyderabad - 500001, Telangana, India

Maher Unnisa, Deccan School of Pharmacy, Dar-us-Salam, Hyderabad - 500001, Telangana, India

Deccan School of Pharmacy, Dar-us-Salam, Hyderabad - 500001, Telangana, India

Shayesta Khan, Deccan School of Pharmacy, Dar-us-Salam, Hyderabad - 500001, Telangana, India

Deccan School of Pharmacy, Dar-us-Salam, Hyderabad - 500001, Telangana, India


1. Duerden M, Avery AJ, Payne RA. Polypharmacy and medicines optimisation: making it safe and sound. London: King's Fund; 2013.
2. Payne R, Franklin BD, Slight S, Avery A. Medication Errors - Technical Series on Safer Primary Care, WHO, United Kingdom; 2016.
3. Tariq RA, Vashisht R, Sinha A, et al. Medication Dispensing Errors and Prevention. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519065/
4. Ferner RE, Aronson JK. Clarification of terminology in medication errors: definitions and classification. Drug Saf. 2006;29:1011-22. https://doi.org/10.2165/00002018-200629110-00001 PMid:17061907
5. Hashemi F, Nasrabadi AN, Asghari F. Factors associated with reporting nursing errors in Iran: A qualitative study. BMC Nurs. 2012;11:20. Available from: http://www.biomedcentral.com/1472-6955/12/20. https://doi.org/10.1186/1472-6955-11-20 PMid:23078517 PMCid:PMC3534596
6. Yoon S, Sohng K. Factors causing medication errors in an electronic reporting system. Nursing Open. 2021;8:3251-3260. https://doi.org/10.1002/nop2.1038 PMid:34392612 PMCid:PMC8510738
7. Fry MM, Dacey C. Factors contributing to incidents in medicine administration. Part 1. Br J Nurs. 2007;16:556-8. https://doi.org/10.12968/bjon.2007.16.9.23435 PMid:17551449
8. Kilonzi M, Mutagonda RF, Mlyuka HJ, Mwakawanga DL, Mikomangwa WP, Kibanga WA, Marealle AI, Mallya B, Katabalo D, Sanga S, Kalokola F. Barriers and facilitators of integration of pharmacists in the provision of clinical pharmacy services in Tanzania. BMC Primary Care. 2023;24(1):72. https://doi.org/10.1186/s12875-023-02026-4 PMid:36932338 PMCid:PMC10021921
9. Santos Júnior GA, Ramos SF, Pereira AM, Dosea AS, Araujo EM, Onozato T, Pimentel DM, Lyra Jr DP. Perceived barriers to the implementation of clinical pharmacy services in a metropolis in Northeast Brazil. PloS one. 2018;13(10):e0206115. https://doi.org/10.1371/journal.pone.0206115 PMid:30346979 PMCid:PMC6197690
10. Al-Ahmadi RF, Al-Juffali L, Al-Shanawani S, Ali S. Categorizing and understanding medication errors in hospital pharmacy in relation to human factors. Saudi Pharmaceutical Journal. 2020;28(12). https://doi.org/10.1016/j.jsps.2020.10.014 PMid:33424260 PMCid:PMC7783100
11. Tariq RA, Vashisht R, Sinha A, Scherbak Y. Medication Dispensing Errors and Prevention.
12. Tam V, Knowles S, Cornish P, Fine N, Marchesano R, Etchells E. Frequency, type and clinical importance of medication history errors at admission to hospital: A systematic review. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2005;173:510-5. https://doi.org/10.1503/cmaj.045311 PMid:16129874 PMCid:PMC1188190
13. D'Errico S, Zanon M, Radaelli D, Padovano M, Santurro A, Scopetti M, Frati P, Fineschi V. Medication Errors in Pediatrics: Proposals to Improve the Quality and Safety of Care Through Clinical Risk Management. Front Med (Lausanne). 2022 Jan 14;8:814100. https://doi.org/10.3389/fmed.2021.814100 PMid:35096903 PMCid:PMC8795662
14. Bante A, Mersha A, Aschalew Z, Ayele A. Medication errors and associated factors among pediatric inpatients in public hospitals of gamo zone, southern Ethiopia. Heliyon. 2023 Apr 11;9(4):e15375. https://doi.org/10.1016/j.heliyon.2023.e15375 PMid:37123938 PMCid:PMC10130860
15. Benavides S, Huynh D, Morgan J, Briars L. Approach to the pediatric prescription in a community pharmacy. J Pediatr Pharmacol Ther. 2011;16(4):298-307. https://doi.org/10.5863/1551-6776-16.4.298 PMid:22768015 PMCid:PMC3385045
16. Palchuk MB, Seger DL, Recklet EG, Hanson C, Alexeyev A, Li Q. Weight-based pediatric prescribing in ambulatory setting. AMIA Annu Symp Proc. 2006;2006:1055.
17. Gore R, Chugh P, Tripathi C, Lhamo Y, Gautam S. Pediatric Off-Label and Unlicensed Drug Use and Its Implications. Current clinical pharmacology. 2017;12. https://doi.org/10.2174/1574884712666170317161935 PMid:28322168
18. Medication Safety: Inaccurate Patient Weight Can Cause Dosing Errors.
19. Medication Wrong-Route Administrations in Relation to Medical Prescriptions Rev. Latino-Am. Enfermagem. 2011;19(1):11-7. www.eerp.usp.br/rlae. https://doi.org/10.1590/S0104-11692011000100003 PMid:21412624
20. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003 Jun 19;348(25):2526-34. https://doi.org/10.1056/NEJMsa020847 PMid:12815139
21. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010 Apr 26;170(8):683-90. https://doi.org/10.1001/archinternmed.2010.65 PMid:20421552
22. Keers RN, Williams SD, Cooke J, Ashcroft DM. Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence. Ann Pharmacother. 2013 Feb;47(2):237-56. https://doi.org/10.1345/aph.1R147 PMid:23386063
23. Dave P. Addressing Disparities in Vision Health and Eye Care in the US. World Journal of Current Medical and Pharmaceutical Research, 2024;6(1):58-64. https://doi.org/10.37022/wjcmpr.v6i1.321
24. Chua SS, Chua HL, Omar A, Azhar ZIM. Drug-related problems in hospitalized patients on polypharmacy: the influence of age and gender. Ther Clin Risk Manag. 2009;5(1):433.
25. Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M. An in-depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. Postgrad Med J. 2007 Jan;83(985):5-10.
26. U.S. Food and Drug Administration. Medication Errors [Internet]. U.S. Department of Health and Human Services; c2013 [cited 2013 Sep 27]. Available from: http://www.fda.gov/drugs/drugsafety/medicationerrors/default.html
27. Zirpe KG, Seta B, Gholap S, Aurangabadi K, Gurav SK, Deshmukh AM, Wankhede P, Suryawanshi P, Vasanth S, Kurian M, Philip E, Jagtap N, Pandit E. Incidence of Medication Error in Critical Care Unit of a Tertiary Care Hospital: Where Do We Stand? Indian J Crit Care Med. 2020 Sep;24(9):799-803. https://doi.org/10.5005/jp-journals-10071-23556 PMid:33132563 PMCid:PMC7584841
28. Linden-Lahti, Carita MSc∗,†; Takala, Anna MSc†; Holmström, Anna-Riia PhD†; Airaksinen, Marja PhD†. What Severe Medication Errors Reported to Health Care Supervisory Authority Tell About Medication Safety?. Journal of Patient Safety 17(8):p e1179-e1185. https://doi.org/10.1097/PTS.0000000000000914 PMid:34569999 PMCid:PMC8612921
29. Wrong Patient Medication Errors: An Analysis of Event Reports in Pennsylvania and Strategies for Prevention [Internet]. n.d. [cited 2013 Sep 27]. Available from: http://www.health.mil/Libraries/PSPDocuments/2013_wrongpatient_prepub.pdf
30. The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines (Basel). 2021 Sep;8(9):46. https://doi.org/10.3390/medicines8090046 PMid:34564088 PMCid:PMC8468915
31. Lester PE, Sahansra S, Shen M, Becker M, Islam S. Medication Reconciliation: An Educational Module. MedEdPORTAL. 2019 Nov 1;15:10852. https://doi.org/10.15766/mep_2374-8265.10852 PMid:31934615 PMCid:PMC6952281
32. Patel E, Pevnick JM, Kennelty KA. Pharmacists and medication reconciliation: a review of recent literature. Integr Pharm Res Pract. 2019;8:39-45. https://doi.org/10.2147/IPRP.S169727 PMid:31119096 PMCid:PMC6500442
33. NICE Medicines and Prescribing Centre (UK). Medicines Optimization: The Safe and Effective Use of Medicines to Enable the Best Possible Outcomes. Manchester: National Institute for Health and Care Excellence (NICE); 2015 Mar. (NICE Guideline, No. 5.) 8, Medication review. Available from: https://www.ncbi.nlm.nih.gov/books/NBK355921/ .
34. Shuib W, Wu XY, Xiao F. Extent, reasons and consequences of off-labeled and unlicensed drug prescription in hospitalized children: a narrative review. World J Pediatr. 2021;17:341-354. https://doi.org/10.1007/s12519-021-00430-3 PMid:34080130
35. Medication errors: problems and recommendations from a consensus meeting Br J Clin Pharmacol. 2009;67(6):592-598. https://doi.org/10.1111/j.1365-2125.2009.03414.x PMid:19594525 PMCid:PMC2723195
36. Agrawal A. Medication errors: prevention using information technology systems. Br J Clin Pharmacol. 2009;67(6):681-6. https://doi.org/10.1111/j.1365-2125.2009.03427.x PMid:19594538 PMCid:PMC2723209
98 Views | 7 Downloads
How to Cite
Unnissa Z, Unnisa M, Khan S. A Comprehensive Review of Medication Errors in Modern Healthcare. JDDT [Internet]. 15May2024 [cited 24Jun.2024];14(5):220-8. Available from: https://jddtonline.info/index.php/jddt/article/view/6565