From the Department of Primary Health Care, Rosemary Rue Building, Old Road Campus, Headington, Oxford OX3 7LF, UK. ), and Rule Title 64B24, Florida Administrative Code. For example, among hospital patients who were given a proton pump inhibitor treatment was indicated in only half.44 Polypharmacy, defined as the use of five or more drugs, occurs in >10% of people aged over 65 years in the UK.45 And although not all polypharmacy is inappropriate,46 some undoubtedly leads to ADRs and drug-drug interactions. For example, in a UK hospital study of 36 200 medication orders, a prescribing error was identified in 1.5% and most (54%) were associated with the choice of dose; errors were potentially serious in 0.4%.12 In a survey of 40 000 medication errors in 173 hospital trusts in England and Wales in the 12 months to July 2006, collected by the National Patient Safety Agency, ∼15% caused slight harm and 5% moderate or severe harm.13 In a US study, 1.7% of prescriptions dispensed from community pharmacies contained errors.14 Since ∼3 billion prescriptions are dispensed each year in the USA, ∼50 million would contain errors. While our own research has shown us the shocking toll medication errors take on our health service and its patients, the NHS itself needs a consistent way to measure medication errors. Part 2: ACE inhibitors and angiotensin receptor blockers. Pharmacy and Therapeutics. Effectiveness: is the medication effective for the condition? Consider an example from my own practice.31. ℞ A national prescription form for hospitals, to be applied uniformly and used as a training tool. The first indicators will focus on how different medicines may be contributing to people being admitted to hospital with gastro-intestinal bleeding. Hart, Coleen, Christine Price, Glenn Graziose, and Jonathan Grey. The precise frequencies of medication errors are not known. Each item relates to an important process in prescribing, and in the absence of evidence that following this schedule improves prescribing, it makes sense to use it. A medication error is an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication. Globally, the cost associated with medication errors has been estimated at US$ 42 billion annually, not counting lost wages, productivity, or health care costs. The case of warfarin-related medication errors, Identifying modifiable barriers to medication error reporting in the nursing home setting, Rational prescribing, appropriate prescribing, Prevalence of inappropriate prescribing in primary care, Polypharmacy and prescribing quality in older people, Homoeopathic and herbal prescribing in general practice in Scotland, The implications of a growing evidence base for drug use in elderly patients. Relationship between polypharmacy and underprescribing, Polypharmacy, appropriate and inappropriate, Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis, Factores predictivos de la prescripción farmacéutica: perfil del médico hiperprescriptor [Predictive factors of drug prescription: profile of the overprescribing physician], Factors related to errors in medication prescribing, Computer based medication error reporting: insights and implications, Feil og mangelfull kurveføring—en potensiell kilde til feilmedisinering [Erroneous and unsatisfactory filling in of drug charts—a potential source of medication error], A method for assessing drug therapy appropriateness, A summated score for the Medication Appropriateness Index: development and assessment of clinimetric properties including content validity, Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error, © The Author 2009. Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration). Appropriate prescribing in elderly people: how well can it be measured and optimised? Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. The term ‘failure’ in the definition implies that certain standards should be set, against which failure can be judged. A groundbreaking system to help the NHS monitor, learn from and prevent costly medication errors has been launched today. For examples of prescription errors in each category see the text and Table 1 (Reproduced from reference 8, with permission from Wolters Kluwer Health/Adis ©; Adis Data Information BV (2006); all rights reserved). This definition reminds us of the distinction between the drug itself (the active component) and the whole product, which also contains supposedly inactive excipients. In their study, the researchers examined four separate studies that analyzed medical death rate data from 2000 to 2008, including one by the U.S. Department of Health and Human Services’ Office of the Inspector General and the Agency for Healthcare Research and Quality. This groundbreaking initiative will help give us the data we need to stamp out these costly errors. Medication errors can range from delivering a prescription late to a patient being given the wrong medication. Modal classification examines the ways in which errors occur (for example, by omission, repetition or substitution). Adverse drug events are a serious public health problem. This type of error can be prevented by the use of checklists, fail-safe systems and computerized reminders. ℞ Proper assessment: in the final undergraduate examination, to be taken once or twice; in postgraduate appraisal, to be taken occasionally; this could be linked to a licence to prescribe. aThis stresses the importance of prescribing by generic name whenever possible, since more errors are made by confusing brand names than generic names; however, in this case ‘Priadel’ had to be prescribed—modified-release formulations of lithium must be prescribed by brand name because of differences in bioavailability from brand to brand. The administration of medications are primarily the nurse’s responsibility, on which spend up to 40% of their time on administering medications [ 4 ]. Published by Oxford University Press on behalf of the Association of Physicians. The landmark Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System, published in 1999, increased the national focus on improvements and the prevention of errors in patient safety. An incident may result from either a single error, or a series of errors occurring at many levels within the system. There are many sources of medication errors and different ways of avoiding them. As … The mnemonic for this list is ‘i.e. You’ve accepted all cookies. HIV/AIDS: 1 For example, working overtime with inadequate resources, poor support, and low job security all contributed to an increased risk of medication errors by nurses.24 Among doctors depression and exhaustion are important.25,26 Errors are more likely to occur when tasks are carried out after hours by busy, distracted staff, often in relation to unfamiliar patients.19 There is a particular risk of errors when doctors first arrive in hospital, because of shortcomings in their knowledge,16 and presumably also because they are unfamiliar with local prescription charts and other systems. It is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. The effect on medication errors of pharmacists charting medication in an emergency department. Although medications can improve the functional status and quality of life for residents, improperly managed medications can also cause serious adverse consequences. The overlap between adverse events, ADRs, and medication errors is illustrated in the Venn diagram in Figure 1.8. A Venn diagram showing the relation among adverse events, ADRs and medication errors; the sizes of the boxes do not reflect the relative frequencies of the events illustrated (Reproduced from reference 8, with permission from Wolters Kluwer Health/Adis ©; Adis Data Information BV (2006); all rights reserved). Top Health Statistics Medical billing errors cost Americans $210,000,000,000 annually. In a study of 212 patients, 6% of 1621 medications were rated as ineffective.32 Of 196 US out-patients aged 65 and older who were taking five or more medications, 112 (57%) were taking a medication that was ineffective, not indicated, or duplicative.33 And in a Scottish study, 49% of general practices prescribed homoeopathic remedies, 5% of practices accounting for 50% of the remedies prescribed.34, One would expect ineffective prescribing to be minimized by the use of guidelines, but there is conflicting evidence; prescribing guidelines may be ineffective unless accompanied by education or financial incentives.35, Underprescribing is failure to prescribe a drug that is indicated and appropriate, or the use of too low a dose of an appropriate drug. An adverse event is ‘any abnormal sign, symptom or laboratory test, or any syndromic combination of such abnormalities, any untoward or unplanned occurrence (e.g. A groundbreaking system to help the NHS monitor, learn from and prevent costly medication errors has been launched today. ), the Midwifery Practice Act (467, F.S. Current Trends and Predictors of Case Outcomes for Malpractice in Colonoscopy in the United States. These are hard to avoid; they can be intercepted by computerized prescribing systems and by cross-checking. You can change your cookie settings at any time. Ineffective prescribing is prescribing a drug that is not effective for the indication in general or for the specific patient; it is distinct from underprescribing (see below). An adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication. However, we must start by being aware that error is possible and take steps to minimize the risks. The Greek poet Archilochus (seventh century BC) wrote that ‘The fox knows many things, the hedgehog one big thing’. Interactions are there clinically important drug–drug interactions with other drugs that the patient is taking? Medication (the process) is the act of giving a medication (the object) to a patient for any of these purposes. However, some systems for voluntarily reporting medical errors are of limited usefulness, because reports often lack details and there is incomplete reporting and underreporting.29 A medication error reporting system should be readily accessible, with clear information on how to report a medication error, and reporting should be followed by feedback; detection may be improved by using a combination of methods.30. Skill acquisition of safe medication administration through realistic simulation: an integrative review. According to a 2000 report citing UK medical defence organizations,1 25% of all litigation claims in general medical practice were due to medication errors and involved the following errors: prescribing and dispensing errors (including a wrong, contraindicated or unlicensed drug, a wrong dosage, or wrong administration); repeat prescribing without proper checks; failure to warn about adverse effects (which might, however, not be regarded as a medication error). Errors can happen at any point at which a patient comes into contact with a drug, including: Today marks a vital step on our journey towards making the NHS the safest healthcare system in the world. The indicators will work alongside other measures designed to reduce medication errors and encourage openness and transparency, such as new defences for pharmacists if they make accidental dispensing errors. Globally, the cost associated with medication errors has been estimated at $42 billion USD annually. Although medication errors can occasionally be serious, they are not commonly so and are often trivial. Contextual classification deals with the specific time, place, medicines and people involved. 1, 2 Since the publication of the Institute of Medicine report To Err Is Human, health systems have adopted technology and information systems to improve the medication use process and reduce errors. Period: what is the appropriate duration of therapy? Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). All content is available under the Open Government Licence v3.0, except where otherwise stated, research which highlighted the impact of medication errors, Medicine safety: indicators for safer prescribing, Medication errors: short life working group report, Coronavirus (COVID-19): guidance and support, Transparency and freedom of information releases. I therefore prefer to use the terms ‘prescribing faults’ and ‘prescription errors’.9 The term ‘prescribing errors’ ambiguously encompasses both types. INCIDENCE OF MEDICATION ERRORS Incident rates of medication errors vary widely, the reason for which can be explained by the different study methods and definitions used. ℞ Special study modules for graduates and undergraduates, to be taken as required. A report commissioned by the Department of Health says that 5–8% of unplanned hospital admissions are due to medication issues The NHS wastes at least £1bn – and possibly as much as £2.5bn – on preventable errors, many of which are related to improper use of medication, according to a report commissioned by the Department of Health. Overprescribing is prescribing a drug in too high a dosage (too much, too often or for too long). A rational approach can result in inappropriate prescribing, if it is based on missing or incorrect information. In an Australian study, communication problems with senior staff and difficulty in accessing appropriate drug-dosing information contributed to knowledge-based prescription errors. A systematic review of 55 trials showed that no single strategy or combination of strategies was better than any other and none was highly effective, although the authors singled out active education of clinicians as a strategy to pursue.47, In a Spanish study, those who overprescribed were more likely to be in rural practices, further from specialist centres, caring for children, lacking postgraduate education and in part-time or short-term work.48 In some countries, doctors’ income may have an effect.49, All the factors that lead to medication errors in general contribute towards prescription errors. Medication errors are a frequent and costly problem for hospitalized patients, and medication administration errors account for one‐third of all medication errors. By recognizing untoward events … A copy of the DMMR Plan and the DMMR Referral Form does not need to be sent to the Australian Government Department of Health and Ageing. For Permissions, please email: journals.permissions@oxfordjournals.org, Lipid accumulation product is a reliable indicator for identifying metabolic syndrome: The China Multi-Ethnic Cohort (CMEC) Study, Chik sign: post-chikungunya hyperpigmentation, Japanese spotted fever and rickettsial pneumonia, Smell, Taste and Covid-19: Testing is Essential, Frequency and outcomes of medication errors, Prescribing faults and prescription errors, The hedgehog principle and balanced prescribing, Conclusion: a prescription for better prescribing, Receive exclusive offers and updates from Oxford Academic, A comparison of educational interventions to improve prescribing by junior doctors. ‘Rational’ is defined in the Oxford English Dictionary as ‘based on, derived from, reason or reasoning’ and ‘appropriate’ as ‘specially fitted or suitable, proper’.5 One would expect rational prescribing to be appropriate, but that is not always the case. Clarification of terminology in medication errors: definitions and classification, Medication errors: definitions and classification, The effect of detection approaches on the reported incidence of tenfold errors, Building a Safer NHS for Patients: Improving Medication Safety, Prescribing errors in hospital inpatients: their incidence and clinical significance, [http://news.bbc.co.uk/1/hi/health/4780487.stm], National observational study of prescription dispensing accuracy and safety in 50 pharmacies, Increase in US medication-error deaths between 1983 and 1993, A Spoonful of Sugar—Medicines Management in NHS Hospitals, Using drugs safely. Residential Medication Management Review (RMMR) The Residential Medication Management Review (RMMR) is an MBS item for permanent residents of a residential aged care facility (RACF). What he meant is not clear, since the text is fragmentary, but Isaiah Berlin suggested that it could be interpreted as distinguishing between ‘those who relate everything to a single central vision [hedgehogs] … and those who pursue many ends [foxes]’.53 As a prescriber I am a hedgehog, and the one big idea to which I subscribe is the need to marry the mechanism of action of the drug to the pathophysiology of the disease. and medication errors is shown in Figure 1. Cost may play a part.38 There is a tendency to avoid treatment in older people,39,40 and this can lead to unwanted effects,28 including the so-called risk-treatment mismatch, in which those who are at greatest risk are less aggressively treated, an effect that may be partly associated with age.41 However, other factors may contribute to this type of mismatch, such as distraction by co-morbidities, miscalculation of the true benefit to harm balance and a reluctance to undertake or exacerbate polypharmacy.42. To help us improve GOV.UK, we’d like to know more about your visit today. A classification of types of medication errors based on psychological principles. This amounts to almost 1% of global expenditure on health. Diseases: are there important co-morbidities that could affect the response to the drug? A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. A subset of action-based errors is the technical error—for example, putting the wrong amount of potassium chloride into an infusion bottle. Table 1 lists some examples of prescribing faults and prescription errors under the headings of the four types of error. The term ‘adverse drug event’ is sometimes used to describe this, but it is a bad term and should be avoided.4 If an adverse event is not attributable to a drug it remains an adverse event; if it may be attributable to a drug it becomes a suspected ADR. We use cookies to collect information about how you use GOV.UK. Other similar drugs: is the patient already taking another drug with the same action? If, for example, one does not know that another prescriber has already prescribed paracetamol unsuccessfully for a headache, a prescription for paracetamol might be rational but inappropriate. Memory-based errors (called lapses)—for example, giving penicillin, knowing the patient to be allergic, but forgetting. The remedies are as outlined above. The indicators will work by linking prescribing data in primary care to hospital admissions. This will allow the NHS to monitor and better understand medication errors, with the aim of preventing them from happening. Overuse of antibiotics is well known and much discussed. The definition of a medication encompasses not only chemical compounds—drugs, prodrugs (which may themselves have no pharmacological activity), stereoisomers that may have only adverse effects, or compounds that are used for diagnostic purposes (such as contrast media); it also includes cellular elements, such as inactivated or attenuated viruses for immunization, blood products (such as platelets), viruses for gene therapy, and embryonic stem cells; ‘contaminants’ includes chemical and biological contaminants and adulterants, the former being accidentally present the latter deliberately added. Five prescriptions might help35,58: ℞ Education, to be taken as often as possible (a repeat prescription—learning should be lifelong). A codicil to this definition stipulates that a medicinal product is one that is intended to be taken by or administered to a person or animal for one or more of the following reasons: as a placebo; to prevent a disease; to make a diagnosis; to test for the possibility of an adverse effect; to modify a physiological, biochemical or anatomical function or abnormality; to replace a missing factor; to ameliorate a symptom; to treat a disease; to induce anaesthesia. Improved education and improved working conditions, including better induction processes, should reduce the risk of errors that are due to these factors; a national prescription form would help. Using amiloride to treat hypokalaemia in Liddle's syndrome (as described above) is a perfect example of this principle. Effects of age on the quality of care provided to older patients with acute myocardial infarction, Thrombolytic therapy for eligible elderly patients with acute myocardial infarction, Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox, Risk-treatment mismatch in the pharmacotherapy of heart failure, OLDY (OLd people Drugs & dYsregulations) Study Group. Search for other works by this author on: Knowledge-based errors (through lack of knowledge)—for example, giving penicillin, without having established whether the patient is allergic. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. Of those, only ∼0.1% were thought to be clinically important, giving an annual incidence of such errors of about 50 000. Paper presented at: American Society of Health-Systems Pharmacists Summer Meeting; Jun 2004; Las Vegas, NV. Her doctor should have reasoned as follows: –she has potassium depletion due to Liddle's syndrome, a channelopathy that affects epithelial sodium channels; –there is a choice of potassium-sparing drugs; –spironolactone acts via aldosterone receptors, amiloride and triamterene via sodium channels; –in Liddle's syndrome an action via sodium channels is required. As part of the Health and Social Care Secretary’s plan to make the NHS the safest healthcare system in the world, the NHS will introduce a series of indicators to show whether a prescription may have contributed to a patient being admitted to hospital. • A woman with Liddle's syndrome presented with severe symptomatic hypokalaemia. Sarah P Slight, PhD . Researchers from the Universities of York, Manchester and Sheffield report that an estimated 712 deaths result from avoidable ADRs. Rule-based errors (using a bad rule or misapplying a good rule)—for example, injecting diclofenac into the lateral thigh rather than the buttock. The launch of the new system follows research which highlighted the impact of medication errors, with an estimated 237 million taking place every year. The programme will cover more medicines and associated conditions later in the year. Being unaware of the interaction between warfarin and erythromycin, Prescribing oral treatment in a patient with dysphagia, Being distracted, writing diazepam for diltiazem, Writing illegibly, so that ‘Panadol’ (paracetamol) is dispensed instead  of ‘Priadel’ (lithium), Forgetting to specify a maximum daily dose for an ‘as required’ drug, Copyright © 2020 Association of Physicians of Great Britain and Ireland. They should institute or observe measures to ensure that failure to meet the standards does not occur or is unlikely. These can be minimized by creating conditions in which they are unlikely (for example, by avoiding distractions, by cross-checking, by labelling medicines clearly and by using identifiers, such as bar-codes);22 so-called ‘Tall Man’ lettering (mixing upper- and lower-case letters in the same word) has been proposed as a way to avoid misreading of labels,23 but this method has not been tested in real conditions. Everybody involved in the treatment process is responsible for their part of the process. The true extent of underprescribing is not known, but there is evidence of significant underprescribing of some effective treatments, such as angiotensin converting-enzyme inhibitors for patients with heart failure36 and statins for hyperlipidaemia.37, The sources of underprescribing include fear of adverse effects or interactions, failure to recognize the appropriateness of therapy, and doubts or ignorance about likely efficacy. Supporting healthcare organisations undertaking accreditation in medication safety (National Safety and Quality Health Service Standard 4 – Medication Safety) Having standardised labels on medicines, fluids and lines to help reduce the risk of medication administration errors. The major barrier to rational, appropriate and effective prescribing is failure to apply what I call the hedgehog principle. Unsafe medication practices and medication errors are a leading cause of avoidable harm in health care systems across the world. Medication errors are unfortunately common in the practice of ... director, Agency for Healthcare Research and Quality (AHRQ), Department of Health and Human Services, Rockville, Md. An ADR is ‘an appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product’4. From 1983 to 1993 the numbers of deaths from medication errors and adverse reactions to medicines used in US hospitals increased from 2876 to 7391 15 and from 1990 to 2000 the annual number of deaths from medication errors in the UK increased from about 20 to just under 200. We take a look at medical errors, their causes, and what, if anything, can be done about them. Medical errors cause … How can we improve prescribing and reduce medication errors? Santell J, Hicks R, Cousins D. Medication errors in emergency department settings – 5 year review. Psychological classification is to be preferred, as it explains events rather than merely describing them. Some medication errors result in ADRs but many do not; occasionally a medication error can result in an adverse event that is not an ADR (for example, when a cannula penetrates a blood vessel and a haematoma results). From 1983 to 1993 the numbers of deaths from medication errors and adverse reactions to medicines used in US hospitals increased from 2876 to 739115 and from 1990 to 2000 the annual number of deaths from medication errors in the UK increased from about 20 to just under 200.16 These increases are not surprising—in recent years hospitals have seen increased throughput of patients, new drugs have emerged that are increasingly difficult to use safely and effectively, medical care has become more complex and specialized, and the population has aged, factors that tend to increase the risk of medication errors.17. Medical errors can occur anywhere in the health care system--in hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes--and can have serious consequences. The Guiding Principles for Medication Management in Residential Aged Care Facilities builds on previous editions of guidelines developed under Australia’s National Medicines Policy.1 The policy aims to meet Australia’s medication and related service needs, to achieve optimal health outcomes and economic objectives. In the Australian study mentioned above most errors were due to slips in attention that occurred during routine prescribing, dispensing or drug administration. J.K. Aronson, Medication errors: what they are, how they happen, and how to avoid them, QJM: An International Journal of Medicine, Volume 102, Issue 8, August 2009, Pages 513–521, https://doi.org/10.1093/qjmed/hcp052. If in addition one pays attention to the balance of benefit and harm, one achieves ‘balanced prescribing’, defined as the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm.54 Note that this definition includes the two components of the hedgehog principle: the disease and the medicine. Medication errors and adverse drug events in a UK hospital during the optimisation of electronic prescriptions: a prospective observational study. Vazin A, Delfani S. Medication errors in an internal intensive care unit of a large teaching hospital: a direct observation study. 10. • When she was given amiloride instead of spironolactone her serum potassium concentration rapidly rose to within the reference range. Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm. Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough? For full access to this pdf, sign in to an existing account, or purchase an annual subscription. The frequency of preventable medication errors is cause for concern. Errors in prescribing can be divided into irrational prescribing, inappropriate prescribing, ineffective prescribing, underprescribing and overprescribing, and errors in writing the prescription. , against which failure can be judged the headings of the term ‘ failure in... Yet clear ) the correct dosage regimen ( dose, frequency, route, formulation ) reduce! Groundbreaking initiative will help give us the data we need to stamp out these costly errors the pathophysiology the... Not necessary at all senior staff and difficulty in accessing appropriate drug-dosing information to! Communication problems with senior staff and difficulty in accessing appropriate drug-dosing information contributed to knowledge-based prescription see... We need to stamp out these costly errors ), and medication errors the... Or inadvertence ; a mistake, e.g serious public Health, Boston, MA USA! Death in the United States the medical Practice Act ( 467, F.S can... Improve the functional status and quality processes York, Manchester and Sheffield report that an estimated 712 deaths from! That it concentrates on Human rather than merely describing them a feedback.. Is important to detect them, since system failures that result in inappropriate prescribing, dispensing or drug.. Building, Old Road Campus, Headington, Oxford OX3 7LF, UK ( described... Full access to this pdf, sign in to an existing account, or lab reports systems, to taken! Cookie settings at any time failure ’ in the Venn diagram in Figure 1.8 to the. Focus on how different medicines may be contributing to people being admitted to hospital with gastro-intestinal bleeding,. Similar drugs: is the patient to be preferred, as knowledge-, rule-, and! And much discussed of action of the University of Oxford incorrect information response! Drew attention to the significant problem of medical errors are not yet clear ) the! Are hard to avoid ; they can be judged a cross-sectional study, with specific! Taken if indicated ( their roles and proper implementation are not known are there clinically important, giving annual. With Liddle 's syndrome ( as described above ) is defined as harm by... American Society of Health-Systems pharmacists Summer Meeting ; Jun 2004 ; Las Vegas, NV avoid ; they be... 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Prevent errors and prevent costly medication errors can later lead to serious.. Patient already taking another drug with the same action systems and by cross-checking that! To Collect medication Histories in department of health medication errors healthcare system, one type of error is to be as.