The most common error reported to the Institute for Safe Medication Practices Medication Errors Reporting Program (MERP) is wrong dose or quantity, according to an ISMP presentation at the ASHP Midyear 2024 Clinical Meeting & Exhibition, in New Orleans.
Of the 1,016 medication errors healthcare providers reported to MERP from July 2023 to June 2024, 300 concerned an improper dose or quantity.
Providers listed many reasons why improper doses and quantities were prepared, including poor design that made labels hard to read or incomplete label information. Human factors were also at play.
“Busyness is an item on here, as well as distraction,” said Christina Michalek, BS, RPh, FASHP, the director of membership and patient safety at ISMP.
In most cases reported to MERP, providers caught an error before it reached a patient. But this was often not true; an error affected a patient in 478 reported cases, with 122 causing significant harm.
In one case, for example, a dosing error arose because a patient’s weight was recorded incorrectly in supporting documentation for a chemotherapy preparation. The correct weight was 47 kg, but a technician entered it as 112.2 kg; in fact, the contrast agent dose was 112.2 MBq. The errant weight led to excessive chemotherapy doses: 2,130 mg of gemcitabine, not 1,480 mg; and 460 mg of carboplatin, not 335 mg.
This caused an emergency department visit for febrile neutropenia and epistaxis, which required cauterization. Reporting organization personnel divulged this voluntarily, Ms. Michalek noted.
Just Culture
“Transcription errors are not as rare as you might believe them to be,” Ms. Michalek said, adding the story was shared as a learning opportunity for other organizations. This is part of ISMP’s “just culture” ethos, which views mistakes as spurs for improvement and not a cause for punishment.
Everyone is fallible and some degree of medication error is inevitable, noted Matthew Grissinger, BSPharm, FASCP, FISMP, the director of education for ISMP. The best defense against medication error is to build systems that reduce cognitive burden on busy pharmacists and technicians, he added.
“We have limited short-term memory and working memory. Cognitively speaking, we can only do one thing at a time,” he said, even those of us who pride ourselves on our multitasking skills.
Mr. Grissinger described a scenario in which paramedics must use a medication kit to assist patients with ST-segment elevation myocardial infarction—a relatively rare event that requires learning on the fly. To boost paramedic confidence and skill with using the kit, he recommended providing illustrations in the kit’s instructions that directly match its layout. This way there is less cognitive load in using the kit, reducing the likelihood for error.
“You’ve got to think about reducing the mental burden of doing something,” Mr. Grissinger said, through thoughtful human factors engineering.
The sources reported no relevant financial disclosures.
This article is from the March 2025 print issue.