Medication Prescribing Error Reporting and Prevention Program: A 14-Year Experience

Timothy S. Lesar, PharmD


August 14, 2000

In This Article

Impact of Medication Prescribing Error Program

The data provided by the described medication prescribing error program has resulted in, or contributed to, numerous changes in the medication-use system at AMC. This impact is seen in both direct specific process improvements, as well as changes in numerous broad-based, operational, clinical aspects of care, and has helped promote a constructive and cooperative approach to medication errors and their prevention. Table 1 lists a number of examples of programs prompted or heavily influenced by the error prevention program. Examples of how information obtained from the prescribing error program is used can be found in the AMC Formulary (Appendix 2), protocols (Appendix 3), and critical care IV drug guidelines (Appendices 4 and 5).

We have found errors to occur in predictable ways and to have a limited number of contributing factors.[9] Systematic collection of prescribing errors has value in providing information regarding the nature of errors and contributors to the occurrence and prevention, even those outside the specific targeted or monitored errors. Thus, lessons learned about errors and their prevention from collecting information from frequently prescribed drug classes such as antibiotics can be applied to lower frequency but high-risk drugs such as chemotherapeutics. Similarly, problems with new agents can often be predicted based on experiences with older agents, and steps to prevent these "predicted" errors can be implemented before the drug is available for use.

The data collected by the described prescribing error program has clearly influenced the perception of, and attitude toward, all types of medication errors and error prevention strategies within the AMC. This has produced fundamental changes in the approach to processes within the pharmacy, nursing, medical staff, risk management, and organization of the medication-use oversight processes (the Medication Use Quality Improvement Team and the Formulary Committee). Implementation of a systematic error documentation program within an organization, such as that described, can be a powerful tool to promote and develop broad-based error prevention processes.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.