FREQUENTLY ASKED QUESTIONS (Faq)

What is the definition of a medication error?
What abbreviations are dangerous?
What is the evidence for discontinuing the use of dangerous abbreviations? (new)
What drug names are frequently confused?
How should Tallman lettering be applied to look-alike/sound-alike drug name pairs? (new)
What national standards are available for benchmarking medication errors?
What is a "high alert" medication?
What is Failure Mode and Effects Analysis…how do I use it?
What are the ten key elements of medication use system?
What is confirmation bias?
What are the characteristics of a non-punitive environment? How many mistakes can an employee make before they are disciplined?
Won’t patients be safe if nurses just followed the ”five rights”?
What is an independent double check…when and how do I do it?
Why are standard concentrations safer than using the Rule of 6 for pediatric drips? (new)

1. What is the definition of a medication error?

The National Coordinating Council for Medication Error and Prevention (NCCMERP) has approved the following as its working definition of medication error:

"... 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. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use".

2. What abbreviations are dangerous?

Prescribers should avoid the use of abbreviations including those for drug names as they can frequently misunderstood. Abbreviations, symbols, and dose designations that have been reported to ISMP through the USP-ISMP Medication Error Reporting Program that have been frequently misinterpreted and involved in harmful medication errors can be found here . The Joint Commission (JC) has established a National Patient Safety Goal that specifies that certain abbreviations must appear on an accredited organization’s do-not-use list as well, which can be found here.

3. What is the evidence for discontinuing the use of dangerous abbreviations?

We often receive requests for an evidence base regarding the use of abbreviations. For example, we have been asked for controlled studies that show populations with a significantly lower incidence of patient harm where "dangerous" abbreviations are not used. There really isn't any research on this topic, just the reports we keep publishing and those that get national press. In fact we often cite a statement by Leape, Berwick, and Bates [JAMA, Volume 288(4). July 24, 2002 (501-7)] saying that a study would never be done on the need for leading zeroes (0.1 mg not .1 mg) and that one isn't necessary. We have always advocated that it’s time to stop thinking "it hasn't happened here so why should I change?" What would make anyone think it won't happen again, to one of their patients, when our newsletter has for years chronicled random repeated deaths and injuries at various hospitals from a handful of bad abbreviations? Here is a link to an article we did a couple of years ago on a case that gained national press:

Click here for the article

If there were any possibility of doing a controlled trial, how many deaths or injuries would be significant enough to convince practitioners that dangerous abbreviations are a real problem? Is it 1 death per 1 million uses? 10 deaths? 100? 1,000? Any healthcare practitioner that has ever been involved in a situation where a patient was harmed from a medication error would definitely say the answer is zero.

On November 23, the Joint Commission hosted the National Summit on Medical Abbreviations with its co-conveners the American College of Physicians, American College of Surgeons, American Dental Association, American Hospital Association, American Medical Association, American Society of Health-System Pharmacists, Institute for Safe Medication Practices, and United States Pharmacopeia. Fifty professional societies and associations and interest groups participated in the Summit to discuss medical errors related to the misuse and misinterpretation of abbreviations, acronyms, and symbols. The objective of the Summit was to reach consensus on the scope and implications of this serious and complex problem and to find reasonable solutions using all of the evidence at hand.

4. What drug names are frequently confused?

Drug names that can be confused, especially those names that look or sound alike, can increase the risk for medication errors. Errors involving these medications may occur when a prescriber interchanges the two medications when writing an order, when someone misinterprets a written order, when a person taking a verbal order does not hear the order as intended, when selecting a medication when entering an order into a computer system or when obtaining a medications for a shelf. A common contributor to these types of name mix-ups is what human-factors experts call confirmation bias (see FAQ #10). ISMP’s List of Confused Drug Names, which includes look-alike and sound-alike name pairs that have been involved in medication errors published in the ISMP Medication Safety Alert! ®, is posted in the Medication Safety Tools section of our website. Errors involving these medications were reported to ISMP through the USP-ISMP Medication Errors Reporting Program (MERP).

The Joint Commission (JC) has established a National Patient Safety Goal that requires each accredited organization identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs. An organization’s list of look-alike/sound-alike drugs must contain a minimum of 10 drug combinations. You can find JC’s list of drug names at JC’s website. Note: Names that appear on JC's list of look-alike or sound-alike names have been noted in with a double asterisk (**) on ISMP’s List of Confused Drug Names.

You can find a complete list of all medication names that have been confused and reported to the USP-ISMP MERP at USP’s website.

5. How should Tallman lettering be applied to look-alike/sound-alike drug name pairs?

Tallman lettering involves highlighting the dissimilar letters in two names to aid in distinguishing between the two. For example, the name pair epinephrine and ephedrine would be written epINEPHrine and epHEDrine. The Office of Generic Drugs requested manufacturers of sixteen look-alike name pairs to voluntarily revise the appearance of their established names in order to minimize medication errors resulting from look-alike confusion, encouraging manufacturers to supplement their applications with revised labels and labeling that visually differentiated their established names with the use of "Tall Man" letters. For more information: http://www.fda.gov/cder/drug/MedErrors/nameDiff.htm

6. What national standards are available for benchmarking medication errors? What is the national medication error rate?

It is currently not possible to set a benchmark. Each hospital or organization is different. The rates are really only a measure of the number of reports at a given institution not the quality of the care given. It is very possible that an institution with a good reporting system, and thus what appears to be a high error rate, may have a safer system. For more detailed information see the following articles.

In addition, The National Coordinating Council for Medication Error Reporting and Prevention (Council), at its June 11/12, 2002, meeting approved a statement refuting the use of medication error rates. The statement, which is posted on the Council's Web site (www.nccmerp.org), states the "Use of medication error rates to compare health care organizations is of no value." The Council has taken this position for the following reasons:

Differences in culture among health care organizations can lead to significant differences in the level of reporting of medication errors.
Differences in the definition of a medication error among health care organizations can lead to significant differences in the reporting and classification of medication errors.
Differences in the patient populations served by various health care organizations can lead to significant differences in the number and severity of medication errors occurring among organizations.
Differences in the type(s) of reporting and detection systems for medication errors among health care organizations can lead to significant differences in the number of medication errors recorded.

According to the statement, The NCC MERP believes that there are no acceptable incidence rates for medication errors. The goal of every health care organization should be to continually improve systems to prevent harm to patients due to medication errors. Health care organizations should monitor actual and potential medication errors that occur within their organization, and investigate the root cause of errors with the goal of identifying ways to improve the medication use system to prevent future errors and potential patient harm. The value of medication error reporting and other data gathering strategies is to provide the information that allows an organization to identify weaknesses in its medication use system and to apply lessons learned to improve the system. The sheer number of error reports is less important than the quality of the information collected in the reports, the health care organization's analysis of the information, and its actions to improve the system to prevent harm to patients."

"The Council's recommendations support the concept that, at this time in the patient safety journey," said John R. Combes, M.D., Council chairperson and senior medical advisor at The Hospital and Healthsystem Association of Pennsylvania and the American Hospital Association, "it is more important to create the open environment that encourages the reporting of errors and near errors than to develop less meaningful comparative error rates. The goal for an organization's medication safety programs," he continued, "is to learn as much as possible about active and latent error and through that understanding prevent harm to patients."

7. What is a "high alert" medication?

While most medications have a large margin of safety, a small number of drugs have a high risk of causing injury when they are misused. We call these "high alert medications" to draw attention to this characteristic so that all involved in their use will treat them with the care and respect that they require. Errors may or may not be more common with these drugs than with the use of any others; however, the consequences of their errors may be devastating. For this reason, special considerations are required. These medications often need to be packaged differently, stored differently, prescribed differently, and administered differently than others. Whenever possible, "forcing functions," methods that make it impossible for the drug to be given in a potentially lethal manner, should be developed and instituted. We recommend some of those forcing functions in the information that follows.
Click on this link for a list of "high alert medications" which can be targeted for specific intervention to reduce the occurrence of medication errors associated with their use. Recommendations in preventing medication errors with "high alert medications" can be found in Medication Errors available from ISMP.

8. What is Failure Mode and Effects Analysis…how do I use it?

Failure Mode and Effects Analysis (FMEA) is a tool used to reduce the frequency and consequences of errors. It is a way of analyzing a systems design in order to evaluate the potential for failures within that system, and determines what the potential effects may be. One way to implement FMEA is to form a committee to identify failure modes. Examples of common failure modes include errors in calculations (doses and flow rates), storage of high alert medications in patient care areas and failure to check patient’s armband before administering medications. You can find more information on the use of FMEA in healthcare at:

Cohen MR, Senders J, Davis NM. Failure Mode and Effects Analysis: A Novel Approach to Avoiding Dangerous Medication Errors and Accidents. Hospital Pharmacy 1994; 29(4): 319-324, 326-328, 330.

Williams, E, Talley T. The use of failure mode effect and criticality analysis in a medication error subcommittee. Hosp Pharm 1994; 29:331-38

9. What are the ten key elements of medication use system?

Medication use is a complex process that comprises the sub-processes of medication prescribing, order processing, dispensing, administration, and effects monitoring. The key elements that most often affect the medication use process, and the common failures and medication errors associated with them are listed below. The interrelationships among these key elements form the structure within which medications are used.

Patient information: Obtaining the patient’s pertinent demographic and clinical information that will assist practitioners in selecting the appropriate medications, doses and routes of administration. Having essential patient information at the time of medication prescribing, dispensing and administration will result in a significant decrease in preventable adverse drug events (ADEs).
Drug information: Providing accurate and usable drug information to all health professionals involved in the medication use process reduces the amount of preventable ADEs. Not only should drug information be readily accessible to the staff through a multitude of sources (drug references, formulary, protocols, dosing scales…), it is imperative that the drug information is up to date as well as accurate.
Communication of drug information: Miscommunication between physicians, pharmacists and nurses is a common cause of medication errors. To minimize the amount of medication errors caused by miscommunication it is always important to verify drug information and eliminate communication barriers.
Drug labeling, packaging and nomenclature: Drug names that look-alike, sound-alike, have confusing drug labeling and non-distinct drug packaging significantly contribute to medication errors. The incidence of medication errors is reduced with the use of proper labeling and the use of unit dose systems within hospitals.
Drug storage, stock and standardization: Standardizing drug administration times, drug concentrations and limiting the dose concentration of drugs available in patient care areas will reduce the risk of medication errors or minimize their consequences should an error occur.
Drug device acquisition, use and monitoring: Appropriate safety assessment of drug delivery devices should be made both prior to their purchase and during their use. Also, a system of independent double-checks should be used within the institution to prevent device related errors such as, selecting the wrong drug or drug concentration, setting the rate improperly, or mixing the infusion line up with another.
Environmental factors: Having a well-designed system offers the best chance of preventing errors; however, sometimes the environment in which we work contributes to medication errors. Environmental factors that often contribute to medications errors include poor lighting, noise, interruptions and a significant workload.
Competency and staff education: Staff education should focus on priority topics, such as: new medications being used in the hospital, high- alert medications, medication errors that have occurred both internally and externally, protocols, policies and procedures related to medication use. Staff education can be an important error preventions strategy when combined with the other key elements for medication safety.
Patient education: Patients must receive ongoing education from physicians, pharmacists and the nursing staff about the brand and generic names of medications they are receiving, their indications, usual and actual doses, expected and possible adverse effects, drug or food interactions, and how to protect themselves from errors. Patients can play a vital role in preventing medication errors when they have been encouraged to ask questions and seek answers about their medications before drugs are dispensed at a pharmacy or administered in a hospital.
Quality processes and risk management: The way to prevent errors is to redesign the systems and processes that lead to errors rather than focus on correcting the individuals who make errors. Effective strategies for reducing errors include making it difficult for staff to make an error and promoting the detection and correction of errors before they reach a patient and cause harm.

Using an interdisciplinary team approach, ISMP can perform risk assessment, assisting facilities in a critical analysis of their medication use systems. This comprehensive analysis is based on ISMP's Ten Key Elements of Medication Safety, and provides an objective perspective to current medication processes.

10. What is confirmation bias?

Confirmation bias refers to a type of selective thinking whereby one selects out what is familiar to them or what they expect to see, rather than what is actually there. Many errors often occur when practitioners, due to familiarity of certain products, see the one they think it is rather than what it is. It is human nature for people to associate items by certain characteristics. It is very important for the health care community to recognize the role that confirmation bias may play in medication errors and to work together to address associated problems.

11. What are the characteristics of a non-punitive environment? How many mistakes can an employee make before they are disciplined?

A non-punitive environment is a confidential reporting system where everyone understands that errors will not be linked to an individual’s performance. In this type of practice environment, it should be easy to report errors, reward error reporting and provide timely feedback to show what is being done to address problems. A non-punitive approach must be applied consistently. Once one person is disciplined for an error, mistakes will be driven underground. Alternate ways should be found to evaluate employee’s total contribution to the organization.

12. Won’t patients be safe if nurses just followed the ”five rights”?

Many nurses during their training have learned about the “five rights” of medication use: the right patient, drug, time, dose and route. However, the “five rights” focus on the nurse’s individual performance and does not reflect that responsibility for accurate drug administration lies with multiple individuals. Although the “five rights” serve as a useful check before administering medications, there are many other contributing factors to a staff member’s failure to accurately verify the “five rights,” despite their best efforts.

13. What is an independent double check…when and how do I do it?

While technological solutions such as computerized prescriber order entry and bar coding systems have great potential to detect human error, manual redundancies such as independent double checks still play an important role in error detection. Studies show that manual redundancies detect about 95% of errors. Independent double checks serve two purposes: to hopefully, though not dependably, detect a serious error before it reaches a patient; and just as important, to bring attention to the systems that allow the introduction of human error. Independent double checks should be done on error prone processes such as the use of high alert medications.

14. Why are standard concentrations safer than using the Rule of 6 for pediatric drips?

(Response taken from the August 7, 2003 issue of the ISMP Medication Safety Alert!^®)

While nurses and house staff may find the Rule of 6 convenient, we’ve previously written about problems with its use (in our June 12, 1999 issue). First, the Rule of 6 is used primarily for nursing IV admixture, an at-risk procedure that bypasses pharmacy preparation and subsequent double-check systems. Additionally, some medications, such as dopamine, may be available in vials of varying concentrations, increasing the risk of an error.

Next, a mathematical calculation is required, which is always an error-prone process if done manually. Obtaining an accurate weight has been a challenge in hospitals that have asked pharmacy to use the Rule of 6 to prepare solutions for nurses. Inconsistency has resulted in problems, too. People who use the Rule of 6 may assume that all solutions dosed in mcg/kg/minute are prepared in this fashion. If a different concentration is used, infusion rates may be adjusted incorrectly.

Another concern is that solutions prepared using the Rule of 6 may result in fluid overload if dose adjustments are necessary. For example, an increase in a dopamine infusion from 5 mcg/kg/minute to 10 mcg/kg/minute would result in an infusion rate of 10 mL/hour, which alone could consume the total daily fluid requirement for a small neonate (240 mL/24 hours). Thus, physicians may order a double or triple concentration, which greatly increases the risk of an error.

Finally, the Rule of 6 results in drug waste. Only a portion of the drug vial is typically needed to prepare the solution, so the remaining drug is wasted or single-dose containers are inappropriately reused. With these problems in mind, and considering the 2003 and 2004 Joint Commission requirements, it’s clear that hospitals need to adopt standard concentrations for pediatric and neonatal solutions, abandon use of the Rule of 6, and have pharmacy prepare and dispense these solutions while on site.

One final note - standard concentrations for infusions will be needed to maximize the functionality of newer “smart pumps,” which alert nurses to unsafe dose limits and programming errors. Your efforts to standardize pediatric drug infusions now will pay off when this technology is available for syringe pumps.