Prevention of medication errors: detection and audit

Br J Clin Pharmacol. 2009 Jun;67(6):651-5. doi: 10.1111/j.1365-2125.2009.03422.x.


1. Medication errors have important implications for patient safety, and their identification is a main target in improving clinical practice errors, in order to prevent adverse events. 2. Error detection is the first crucial step. Approaches to this are likely to be different in research and routine care, and the most suitable must be chosen according to the setting. 3. The major methods for detecting medication errors and associated adverse drug-related events are chart review, computerized monitoring, administrative databases, and claims data, using direct observation, incident reporting, and patient monitoring. All of these methods have both advantages and limitations. 4. Reporting discloses medication errors, can trigger warnings, and encourages the diffusion of a culture of safe practice. Combining and comparing data from various and encourages the diffusion of a culture of safe practice sources increases the reliability of the system. 5. Error prevention can be planned by means of retroactive and proactive tools, such as audit and Failure Mode, Effect, and Criticality Analysis (FMECA). Audit is also an educational activity, which promotes high-quality care; it should be carried out regularly. In an audit cycle we can compare what is actually done against reference standards and put in place corrective actions to improve the performances of individuals and systems. 6. Patient safety must be the first aim in every setting, in order to build safer systems, learning from errors and reducing the human and fiscal costs.

MeSH terms

  • Adverse Drug Reaction Reporting Systems / organization & administration*
  • Adverse Drug Reaction Reporting Systems / standards
  • Humans
  • Medical Audit*
  • Medication Errors / prevention & control*
  • Medication Systems, Hospital / organization & administration*
  • Medication Systems, Hospital / standards
  • Safety Management / organization & administration*
  • Safety Management / standards