Medication Safety and Patient Safety Week- Playing it safe

October 31 to November 4, 2011 is the Seventh Annual Canadian Patient Safety Week with the theme "ask listen talk" aimed at raising awareness of patient safety issues and solutions. Obviously pharmacists have a key role and responsibility in ensuring safe medication use with every patient encounter every day: from recommending non-prescription products to dispensing a prescription to performing medication reviews.


Medication errors can be defined as "... any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer."1 Some medication errors are corrected before they reach the patient, or reach the patient but cause no harm.  Some errors result in harm varying from minor transient side effects, to those requiring additional interventions, increased monitoring, hospitalization, or even death.1,2


The data on rates and impact of medication errors and preventable adverse drug events, especially in the Canadian ambulatory setting, is sparse, but available reports indicate that medication safety problems remain a serious concern:

  • 12% of visits to Vancouver General Hospital ER were for medication-related problems; 85% were moderate to severe, and 66% were considered preventable. Adverse drug reactions, non-adherence to therapy, and wrong or suboptimal drug treatment were the leading reasons for medication-related visits.3
  • In a recent international survey of patients in Canada, the US, Australia, and Europe  5 to 8% of patients reported receiving the wrong medication or the wrong dose at a pharmacy or in hospital in the past 2 years;4 up to 18% of patients in North America have experienced a medication error sometime in their life.5
  • Using trained shoppers, the dispensing error rate in community pharmacies was 22% in one recent US study , of which 3% were potentially harmful.6

The literature also indicates that certain populations (e.g. elderly or pediatric, liver or kidney disease, mentally ill) are at higher risk for medication errors and adverse drug events.7-9


Medication use can be discussed as a series of processes and subprocesses beginning with the prescription, followed in order by transcription and verification, dispensing, administration and consumption, monitoring and evaluation.5  The medication use system depends on patient data, drug information, staff and patient education, and well-designed systems and environments to minimize the chance of error.10 The goal is getting the right drug, in the right dose, to the right patient by the right route, at the right time, for the right reason, with the right documentation (Figure 1).  The many ways medication safety can be improved in individual practice and patient situations is beyond the scope of this article. However, identifying deficiencies in the key elements above or in the medication use processes, and whether the "right" goals have been met (and if not, why not) can help identify problem areas.


When things go wrong - report it!

As with adverse drug reactions, reporting and analyzing medication errors (including near misses) is key to prevention. Under-reporting hinders preventative measures. "Only by sharing the information can we ensure that everyone learns how to prevent the same error."11 Health professionals and patients can report medication errors freely and anonymously via the Institute for Safe Medication Practices Canada website.


Figure 1: Key elements, processes, and goals of the medication use system

Key elements:


Medication use processes:

to achieve


Patient information

(e.g. age, weight, allergies, lab results, comorbidities, preferences)

Optimal prescribing

Order transcription and verification

Product selection and dispensing

Medication administration and consumption

Monitoring and evaluation of therapy

Right drug

Is this the right drug for this patient? Is it the right product and strength?

Right dose

Is this the right dose for this patient?

Right patient

Has the patient identity been verified?

Right route

Right time

Are labeled directions clear and understood by the patient or caregiver?

Right reason

Is there an indication for the drug? Is there a condition in need of treatment?

Right documentation

Are problems, treatment plans, and changes documented and communicated to those who need to know?

Current, accurate, and accessible drug information and clear communication of the same

Safe drug nomenclature, labeling and packaging (e.g. be aware of look-alike, sound-alike drugs)

Standardization (e.g. administration times, drug strengths or concentrations)

Safe technologies and practices (e.g. drug delivery devices, independent double checks)

Reduction of environmental factors that can lead to errors

(e.g. poor lighting, distractions, poor workflow, high workloads)

Staff competency and education

Patient education and encouragement (e.g. ensure patients know and understand what they are taking and why; encourage them to ask questions, seek answers, and report concerns)

Quality processes and risk management strategies (e.g. redesign systems and processes that lead to errors; improve detection and correction of errors before they reach the patient)

Helpful online resources:
Canadian Patient Safety Institute:

Institute for safe Medication Practices Canada:

Safer Healthcare Now!:


Written by Raymond Li, BSc(Pharm), MSc. Reviewed by Laird Birmingham, MD, FRCPC, MHSc



  1. National Coordinating Council for Medication Error Reporting and Prevention. Available from URL: Accessed 11/09/11.
  2. Gandhi TK, et al. Adverse drug events in ambulatory care. NEJM. 2003; 348: 1556-64.
  3. Zed PJ, et al. Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study. CMAJ. 2008 Jun 3;178(12):1563-9.
  4. Lu CY, Roughead E. Determinants of patient-reported medication errors: a comparison among seven countries. Int J Clin Pract. 2011; 65: 733-40.
  5. Ackroyd-Stolarz S et al. Approaches to improving the safety of the medication use system. Healthc Quart. 2005; 8(special issue): 59-64.
  6. Flynn EA, et al. Dispensing errors and counseling quality in 100 pharmacies. J Am Pharm Assoc. 2009; 49: 171-80.
  7. Bhardwaja B, et al. Improving prescribing safety in patients with renal insufficiency in the ambulatory setting: the Drug Renal Alert Pharmacy (DRAP) Program. Pharmacother. 2011; 31: 346-56.
  8. Procyshyn RM, Barr AM, Brickell T, et al. Medication errors in psychiatry. CNS Drugs. 2010: 24: 595-609.
  9. Onder G, et al. development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 years or older. Arch Intern Med. 2010; 170: 1142-8.3
  10. Institute for Safe Medication Practices. What are the "ten key elements" of the medication-use system? Available from URL: Accessed 11/09/11.
  11. ISMP Canada (

©2012 B.C. Drug and Poison Information Centre

A version of this document was published in BCPhA's The Tablet. 2011; 20(5): 22-23.