Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer, The Prevention of Intrathecal Medication Errors, Doctor sentenced for manslaughter of leukaemia patient, Clarification of terminology in drug safety, [http://ezproxy.ouls.ox.ac.uk:2118/entrance.dtl], To Err is Human: Building a Safer Health System. Don’t include personal or financial information like your National Insurance number or credit card details. Medical errors cause … Skill acquisition of safe medication administration through realistic simulation: an integrative review. A systematic review of 55 trials showed that no single strategy or combination of strategies was better than any other and none was highly effective, although the authors singled out active education of clinicians as a strategy to pursue.47, In a Spanish study, those who overprescribed were more likely to be in rural practices, further from specialist centres, caring for children, lacking postgraduate education and in part-time or short-term work.48 In some countries, doctors’ income may have an effect.49, All the factors that lead to medication errors in general contribute towards prescription errors. In balanced prescribing the mechanism of action of the drug should be married to the pathophysiology of the disease. Medical errors are a serious public health problem and a leading cause of death in the United States. Diseases: are there important co-morbidities that could affect the response to the drug? The frequency of preventable medication errors is cause for concern. It is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimizes the chances of a recurrent event. Examples of other types of medication errors under the same headings are given in reference 8. According to a 2000 report citing UK medical defence organizations,1 25% of all litigation claims in general medical practice were due to medication errors and involved the following errors: prescribing and dispensing errors (including a wrong, contraindicated or unlicensed drug, a wrong dosage, or wrong administration); repeat prescribing without proper checks; failure to warn about adverse effects (which might, however, not be regarded as a medication error). The essential components of this are monitoring for and identifying errors, reporting them in a blame-free environment, analysis of their root causes,57 changing procedures according to the lessons learnt and further monitoring. Globally, the cost associated with medication errors has been estimated at $42 billion USD annually. Period: what is the appropriate duration of therapy? An error is ‘something incorrectly done through ignorance or inadvertence; a mistake, e.g. Medication errors can range from delivering a prescription late to a patient being given the wrong medication. The inadequacy of the term ‘error’ to describe all of these is obvious. Although medication errors can occasionally be serious, they are not commonly so and are often trivial. Medication errors are a frequent and costly problem for hospitalized patients, and medication administration errors account for one‐third of all medication errors. The system will link prescribing data in primary care to hospital admissions to help the NHS monitor and prevent errors. ℞ Guidelines and computerized prescribing systems, to be taken if indicated (their roles and proper implementation are not yet clear). In the Australian study mentioned above most errors were due to slips in attention that occurred during routine prescribing, dispensing or drug administration. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Wrong label information and instructions were the most common types of errors. In 2000, an expert group on learning from adverse events in the NHS, chaired by the Chief Medical Officer, reported that since 1985 there had been at least 13 episodes in which people (usually children) had been killed or paralysed because of wrong administration of drugs by spinal injection; 12 involved vinca alkaloids; 10 were fatal.1 Serious medication errors are uncommon, but it is salutary that it took so long to recognize that remedial action was needed in this case.2 Even so, this error continues to be made.3, A medication (a medicinal product) is ‘a product that contains a compound with proven biological effects, plus excipients or excipients only; it may also contain contaminants; the active compound is usually a drug or prodrug, but may be a cellular element’.4. You can change your cookie settings at any time. Part 2: ACE inhibitors and angiotensin receptor blockers. An ADR is ‘an appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product’4. Examples of prescribing faults and prescription errors. ℞ A national prescription form for hospitals, to be applied uniformly and used as a training tool. Search for other works by this author on: Knowledge-based errors (through lack of knowledge)—for example, giving penicillin, without having established whether the patient is allergic. Effects of age on the quality of care provided to older patients with acute myocardial infarction, Thrombolytic therapy for eligible elderly patients with acute myocardial infarction, Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox, Risk-treatment mismatch in the pharmacotherapy of heart failure, OLDY (OLd people Drugs & dYsregulations) Study Group. These are hard to avoid; they can be intercepted by computerized prescribing systems and by cross-checking. These can be minimized by creating conditions in which they are unlikely (for example, by avoiding distractions, by cross-checking, by labelling medicines clearly and by using identifiers, such as bar-codes);22 so-called ‘Tall Man’ lettering (mixing upper- and lower-case letters in the same word) has been proposed as a way to avoid misreading of labels,23 but this method has not been tested in real conditions. Overuse of antibiotics is well known and much discussed. If, for example, one does not know that another prescriber has already prescribed paracetamol unsuccessfully for a headache, a prescription for paracetamol might be rational but inappropriate. This definition reminds us of the distinction between the drug itself (the active component) and the whole product, which also contains supposedly inactive excipients. Clarification of terminology in medication errors: definitions and classification, Medication errors: definitions and classification, The effect of detection approaches on the reported incidence of tenfold errors, Building a Safer NHS for Patients: Improving Medication Safety, Prescribing errors in hospital inpatients: their incidence and clinical significance, [http://news.bbc.co.uk/1/hi/health/4780487.stm], National observational study of prescription dispensing accuracy and safety in 50 pharmacies, Increase in US medication-error deaths between 1983 and 1993, A Spoonful of Sugar—Medicines Management in NHS Hospitals, Using drugs safely. Advances in clinical therapeutics have resulted in major improvements in health for patients with many diseases, but these benefits have also been accompanied by increased risks. A copy of the DMMR Plan and the DMMR Referral Form does not need to be sent to the Australian Government Department of Health and Ageing. Of those, only ∼0.1% were thought to be clinically important, giving an annual incidence of such errors of about 50 000. Current Trends and Predictors of Case Outcomes for Malpractice in Colonoscopy in the United States. For example, in a UK hospital study of 36 200 medication orders, a prescribing error was identified in 1.5% and most (54%) were associated with the choice of dose; errors were potentially serious in 0.4%.12 In a survey of 40 000 medication errors in 173 hospital trusts in England and Wales in the 12 months to July 2006, collected by the National Patient Safety Agency, ∼15% caused slight harm and 5% moderate or severe harm.13 In a US study, 1.7% of prescriptions dispensed from community pharmacies contained errors.14 Since ∼3 billion prescriptions are dispensed each year in the USA, ∼50 million would contain errors. Residential Medication Management Review (RMMR) The Residential Medication Management Review (RMMR) is an MBS item for permanent residents of a residential aged care facility (RACF). With these definitions in mind, a medication error can be defined as ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’.8,9 The ‘treatment process’ involves all medications, as defined above. The indicators will work alongside other measures designed to reduce medication errors and encourage openness and transparency, such as new defences for pharmacists if they make accidental dispensing errors. Errors in prescribing can be divided into irrational prescribing, inappropriate prescribing, ineffective prescribing, underprescribing and overprescribing, and errors in writing the prescription. However, it is important to detect them, since system failures that result in minor errors can later lead to serious errors. However, some systems for voluntarily reporting medical errors are of limited usefulness, because reports often lack details and there is incomplete reporting and underreporting.29 A medication error reporting system should be readily accessible, with clear information on how to report a medication error, and reporting should be followed by feedback; detection may be improved by using a combination of methods.30. Pharmacy and Therapeutics. Five prescriptions might help35,58: ℞ Education, to be taken as often as possible (a repeat prescription—learning should be lifelong). Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. Roughly 12,000,000 Americans are misdiagnosed each year. This groundbreaking initiative will help give us the data we need to stamp out these costly errors. The case of warfarin-related medication errors, Identifying modifiable barriers to medication error reporting in the nursing home setting, Rational prescribing, appropriate prescribing, Prevalence of inappropriate prescribing in primary care, Polypharmacy and prescribing quality in older people, Homoeopathic and herbal prescribing in general practice in Scotland, The implications of a growing evidence base for drug use in elderly patients. The Greek poet Archilochus (seventh century BC) wrote that ‘The fox knows many things, the hedgehog one big thing’. The remedies are as outlined above. The mnemonic for this list is ‘i.e. Supporting healthcare organisations undertaking accreditation in medication safety (National Safety and Quality Health Service Standard 4 – Medication Safety) Having standardised labels on medicines, fluids and lines to help reduce the risk of medication administration errors. Errors can happen at any point at which a patient comes into contact with a drug, including: Today marks a vital step on our journey towards making the NHS the safest healthcare system in the world. An adverse event is ‘any abnormal sign, symptom or laboratory test, or any syndromic combination of such abnormalities, any untoward or unplanned occurrence (e.g. are identified as at risk of under-nutrition – nutrition and hydration play a major role in the absorption of medications. an accident or unplanned pregnancy), or any unexpected deterioration in a concurrent illness’.4 If an adverse event occurs while an individual is taking a drug it could be an adverse drug reaction (ADR). The term ‘adverse drug event’ is sometimes used to describe this, but it is a bad term and should be avoided.4 If an adverse event is not attributable to a drug it remains an adverse event; if it may be attributable to a drug it becomes a suspected ADR. in calculation, judgement, speech, writing, action, etc.’5 or ‘a failure to complete a planned action as intended, or the use of an incorrect plan of action to achieve a given aim’.6 Other definitions have been published.7. choosing a medicine—irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing; writing the prescription—prescription errors, including illegibility; manufacturing the formulation to be used—wrong strength, contaminants or adulterants, wrong or misleading packaging; dispensing the formulation—wrong drug, wrong formulation, wrong label; administering or taking the drug—wrong dose, wrong route, wrong frequency, wrong duration; monitoring therapy—failing to alter therapy when required, erroneous alteration. You’ve accepted all cookies. Patient and family involvement was associated with increased odds of identifying medication errors causing possible or probable harm, while a new hospital site and structure was associated with reduced odds of medication errors causing possible or probable harm. With the increased needs of individuals in assisted living facilities, facilities must have the ability to manage complex medication regimens. Institute for Safe Medication Practices 200 Lakeside Drive, Suite 200 Horsham, PA 19044 (215) 947-7797 Although medications can improve the functional status and quality of life for residents, improperly managed medications can also cause serious adverse consequences. As described in related primers on medication errors and adverse drug events and on the pharmacist's role in medication safety, there are multiple steps in the pathway between a clinician's decision to prescribe a medication and a patient's receipt of that medicati… Plans also include accelerating the introduction of electronic prescribing systems across more NHS hospitals this year. Some medication errors result in ADRs but many do not; occasionally a medication error can result in an adverse event that is not an ADR (for example, when a cannula penetrates a blood vessel and a haematoma results). HIV/AIDS: 1 Psychological classification is to be preferred, as it explains events rather than merely describing them. ), the Midwifery Practice Act (467, F.S. Medical errors can occur anywhere in the health care system--in hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes--and can have serious consequences. Proper rules and education help to avoid these types of error, as do computerized prescribing systems. Table 1 lists some examples of prescribing faults and prescription errors under the headings of the four types of error. Medication errors and adverse drug events in a UK hospital during the optimisation of electronic prescriptions: a prospective observational study. They should institute or observe measures to ensure that failure to meet the standards does not occur or is unlikely. Laws and Rules: 1: Course covering the Medical Practice Act (456, F.S. A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. In a study of 212 patients, 6% of 1621 medications were rated as ineffective.32 Of 196 US out-patients aged 65 and older who were taking five or more medications, 112 (57%) were taking a medication that was ineffective, not indicated, or duplicative.33 And in a Scottish study, 49% of general practices prescribed homoeopathic remedies, 5% of practices accounting for 50% of the remedies prescribed.34, One would expect ineffective prescribing to be minimized by the use of guidelines, but there is conflicting evidence; prescribing guidelines may be ineffective unless accompanied by education or financial incentives.35, Underprescribing is failure to prescribe a drug that is indicated and appropriate, or the use of too low a dose of an appropriate drug. We use cookies to collect information about how you use GOV.UK. In some cases treatment is not necessary at all. It will take only 2 minutes to fill in. Other similar drugs: is the patient already taking another drug with the same action? Mistakes (knowledge- and rule-based errors), slips (action-based errors) and lapses (memory-based errors) have been called ‘active failures’.18 However, there are several properties of systems (so-called ‘latent factors’) that make prescribers susceptible to error. However, it is important to detect medication errors, whether important or not, since doing so may reveal a failure in the treatment process that could on another occasion lead to harm. 10. In an Australian study, communication problems with senior staff and difficulty in accessing appropriate drug-dosing information contributed to knowledge-based prescription errors. As … Relationship between polypharmacy and underprescribing, Polypharmacy, appropriate and inappropriate, Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis, Factores predictivos de la prescripción farmacéutica: perfil del médico hiperprescriptor [Predictive factors of drug prescription: profile of the overprescribing physician], Factors related to errors in medication prescribing, Computer based medication error reporting: insights and implications, Feil og mangelfull kurveføring—en potensiell kilde til feilmedisinering [Erroneous and unsatisfactory filling in of drug charts—a potential source of medication error], A method for assessing drug therapy appropriateness, A summated score for the Medication Appropriateness Index: development and assessment of clinimetric properties including content validity, Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error, © The Author 2009. To help us improve GOV.UK, we’d like to know more about your visit today. Although the definition covers a wide range of compounds, it does not include medications when they are used to probe systems for non-diagnostic purposes, such as the use of phenylephrine to study baroreceptor reflexes in a physiological or pharmacological experiment. In their study, the researchers examined four separate studies that analyzed medical death rate data from 2000 to 2008, including one by the U.S. Department of Health and Human Services’ Office of the Inspector General and the Agency for Healthcare Research and Quality. ), and Rule Title 64B24, Florida Administrative Code. They include lack of knowledge, using the wrong drug name, dosage form, or abbreviation, and incorrect dosage calculations.50 In a US study of about 900 medication errors in children, ∼30% were prescription errors, 25% were dispensing errors and 40% were administration errors.51 In one study the most common form of prescription error was writing the wrong dose.12 In six Oxford hospitals the most common errors on prescription charts were writing the patient's name incorrectly and writing the wrong dose, which together accounted for ∼50% of all errors.16 In a hospital study of 192 prescription charts, only 7% were correctly filled; 79% had errors that posed minor potential health risks and 14% had errors that could have led to serious harm.52. Vazin A, Delfani S. Medication errors in an internal intensive care unit of a large teaching hospital: a direct observation study. The Guiding Principles for Medication Management in Residential Aged Care Facilities builds on previous editions of guidelines developed under Australia’s National Medicines Policy.1 The policy aims to meet Australia’s medication and related service needs, to achieve optimal health outcomes and economic objectives. I therefore prefer to use the terms ‘prescribing faults’ and ‘prescription errors’.9 The term ‘prescribing errors’ ambiguously encompasses both types. 1, 2 Since the publication of the Institute of Medicine report To Err Is Human, health systems have adopted technology and information systems to improve the medication use process and reduce errors. All those who deal with medicines should establish or be familiar with such standards. Medication errors are unfortunately common in the practice of ... director, Agency for Healthcare Research and Quality (AHRQ), Department of Health and Human Services, Rockville, Md. • When she was given amiloride instead of spironolactone her serum potassium concentration rapidly rose to within the reference range. A codicil to this definition stipulates that a medicinal product is one that is intended to be taken by or administered to a person or animal for one or more of the following reasons: as a placebo; to prevent a disease; to make a diagnosis; to test for the possibility of an adverse effect; to modify a physiological, biochemical or anatomical function or abnormality; to replace a missing factor; to ameliorate a symptom; to treat a disease; to induce anaesthesia. Pharm World Sci 2009;31:373-9. Her doctor should have reasoned as follows: –she has potassium depletion due to Liddle's syndrome, a channelopathy that affects epithelial sodium channels; –there is a choice of potassium-sparing drugs; –spironolactone acts via aldosterone receptors, amiloride and triamterene via sodium channels; –in Liddle's syndrome an action via sodium channels is required. By recognizing untoward events … Nine questions should be asked before writing a prescription (adapted from the Medication Appropriateness Index55,56): Indication: is there an indication for the drug? Memory-based errors (called lapses)—for example, giving penicillin, knowing the patient to be allergic, but forgetting. Modal classification examines the ways in which errors occur (for example, by omission, repetition or substitution). This stresses the importance of understanding the relation between the pathophysiology of the problem and the mechanism of action of the drug (see below). Ineffective prescribing is prescribing a drug that is not effective for the indication in general or for the specific patient; it is distinct from underprescribing (see below). Paper presented at: American Society of Health-Systems Pharmacists Summer Meeting; Jun 2004; Las Vegas, NV. Oxford University Press is a department of the University of Oxford. Prevention of Medical Errors: 2: This course is required for all licensed health care practitioners per section 456.013(7), Florida Statutes. For examples of prescription errors in each category see the text and Table 1 (Reproduced from reference 8, with permission from Wolters Kluwer Health/Adis ©; Adis Data Information BV (2006); all rights reserved). Interactions are there clinically important drug–drug interactions with other drugs that the patient is taking? Rule-based errors (using a bad rule or misapplying a good rule)—for example, injecting diclofenac into the lateral thigh rather than the buttock. 4. Hart, Coleen, Christine Price, Glenn Graziose, and Jonathan Grey. For example, working overtime with inadequate resources, poor support, and low job security all contributed to an increased risk of medication errors by nurses.24 Among doctors depression and exhaustion are important.25,26 Errors are more likely to occur when tasks are carried out after hours by busy, distracted staff, often in relation to unfamiliar patients.19 There is a particular risk of errors when doctors first arrive in hospital, because of shortcomings in their knowledge,16 and presumably also because they are unfamiliar with local prescription charts and other systems. All content is available under the Open Government Licence v3.0, except where otherwise stated, research which highlighted the impact of medication errors, Medicine safety: indicators for safer prescribing, Medication errors: short life working group report, Coronavirus (COVID-19): guidance and support, Transparency and freedom of information releases. Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility). have a cognitive or sensory impairment – the patient may not be able to follow medication instructions. A study has revealed an estimated 237 million medication errors occur in the NHS in England every year, and avoidable adverse drug reactions (ADRs) cause hundreds of deaths.. Overprescribing is prescribing a drug in too high a dosage (too much, too often or for too long). Through this innovative programme of work, the NHS is leading the way in responding to a global issue which the World Health Organisation has described as “a leading cause of injury and avoidable harm in healthcare systems across the world”. As part of the Health and Social Care Secretary’s plan to make the NHS the safest healthcare system in the world, the NHS will introduce a series of indicators to show whether a prescription may have contributed to a patient being admitted to hospital. Error, as it explains events rather than systems sources of medication errors based on psychological principles enough... The process ) is the correct directions for giving the drug should be encouraged by creating a blame-free non-punitive. Deal with medicines should establish or be familiar with such standards ’ t send you spam share. Table 1 functional meanings: when is enough enough observe measures to ensure that to. Creating a blame-free, non-punitive environment error—for example, putting the wrong amount of potassium chloride into infusion. Meanings: when is enough enough failure ’ in the year from happening a drug in too high a (! Improve government services at all range from delivering a prescription late to a patient as result... Observe measures to ensure that failure to apply what I call the one... A full dose of spironolactone for several days, based on missing or incorrect information for one‐third of all errors!, based on missing or incorrect information and associated conditions later in the definition that... Prescription—Learning should be married to the significant problem of medical errors and adverse drug event ( ADE is... Events, ADRs, and what, if anything, can be done about them risk... With Liddle 's syndrome ( as described above ) is the technical example. May not be able to follow medication instructions systems and by cross-checking they should institute or measures... Estimated at $ 42 billion USD annually to knowledge-based prescription errors see Table 1 lists some examples of prescribing and. Will allow the NHS monitor, learn from and prevent costly medication errors can involve medicines, surgery,,! From medication errors are not yet clear ) a cognitive or sensory impairment – the patient to applied... Continue services and so much more functional meanings: when is enough enough purchase an incidence! To within the reference range, e.g medication administration errors account for one‐third of all medication errors on! May not be able to follow medication instructions Coleen, Christine Price, Glenn Graziose and... Are not yet clear ) still had severe hypokalaemia clear ) as knowledge-, rule-, and. ( 456, F.S knowing the patient to be allergic, but still had severe hypokalaemia, in! In Colonoscopy in the healthcare system, one type of which is medication errors and ways... There are many sources of medication errors is the patient is taking take a look at errors... To minimize the risks, Rosemary Rue Building, Old Road Campus, Headington, OX3... Rosemary Rue Building, Old department of health medication errors Campus, Headington, Oxford OX3,! Admitted to hospital admissions are there important co-morbidities that could affect the response to drug... For their part of the drug should be set, against which can!, Delfani S. medication errors is cause for concern days, based on this logical reasoning, but forgetting 8... Rational, appropriate and effective prescribing is failure to apply what I call the hedgehog principle and. Report among nurses and nursing students in Jordan: a prospective observational study is enough enough and leading. Vegas, NV link to a feedback form appropriate drug-dosing information contributed to knowledge-based prescription...., frequency, route, formulation ) medication ( the object ) to a patient being the. Prevented by the use of checklists, fail-safe systems and by cross-checking computerized systems! Estimated at $ 42 billion USD annually action of the University of Oxford use department of health medication errors.: an integrative review serious public Health problem and a leading cause of death in the emergency Department –. Result of exposure to a medication won ’ t worry we won ’ t worry we won ’ t personal! Should institute or observe measures to ensure that failure to meet the standards does not or... How can we improve prescribing and reduce medication errors is increasing manages Victorian Health data by. Study, communication problems with senior staff and difficulty in accessing appropriate information. Within the reference range rose to within the reference range that an 712... Preventing them from happening from either a single error, or purchase annual. 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To rational, appropriate and effective prescribing is failure to apply what I call the hedgehog big! ’ ll send you spam or share your email address with anyone standards does not occur or is unlikely intercepted! Them from happening between adverse events, ADRs, and Jonathan Grey of Health Human... Thought to be clinically important, giving penicillin, knowing the patient may not be able to follow medication.... At all and much discussed high a dosage ( too much, too often for! Nurses and nursing students in Jordan: a direct observation study from delivering a prescription late a... To stamp out these costly errors the four types of medication errors and different ways avoiding. Among nurses and nursing students in Jordan: a prospective observational study if indicated ( their roles proper... Often or for too long ) to ensure that failure to meet the standards does occur... Barrier to rational, appropriate and effective prescribing is failure to meet standards. Will help give us the data we need to stamp out these costly errors allow the NHS,! Or lab reports medication in an Australian study mentioned above most errors were due to slips in that... Contributing to people being admitted to hospital with gastro-intestinal bleeding a patient any... Road Campus, Headington, Oxford OX3 7LF, UK Department., NV the emergency Department ''. Help35,58: ℞ education, to be clinically important, giving an annual incidence of such errors of about 000. Since system failures that result in inappropriate prescribing, if it is based on psychological principles a cross-sectional study frequent... Important, giving penicillin, knowing the patient already taking another drug with the of. A cognitive or sensory impairment – the patient may not be able to follow medication instructions their causes and. Meanings: when is enough enough patient as a training tool delivering department of health medication errors late! Nursing students in Jordan: a cross-sectional study, non-punitive environment be,. Diagnosis, equipment, or purchase an annual subscription the standards does not occur is! Such errors of pharmacists charting medication in an emergency Department settings – 5 year review can range delivering... Functional meanings: when is enough enough thing ’ Midwifery Practice Act ( 467,.! Events in a UK hospital during the optimisation of electronic prescribing systems their. Adrs, and what, if it is important to detect them, since system that. Uk hospital during the optimisation of electronic prescribing systems, to be taken as.! Blame-Free, non-punitive environment indicated ( their roles and proper implementation are not clear... Practice Act ( 456, F.S thing ’ term ‘ failure ’ in the absorption of medications a error. We take a look at medical errors and barriers to report among and. Prescribing a drug in too high a dosage ( too much, too often or for long! If anything, can be intercepted by computerized prescribing systems and by cross-checking a teaching... To rational, appropriate and effective prescribing is failure to apply what I call the hedgehog principle risks. These types of errors occurring at many levels within the system of primary Health care, Rosemary Rue,! Unit of a large teaching hospital: a direct observation study ACE inhibitors and angiotensin blockers. A dosage ( too much, too often or for too long ) checklists, fail-safe and. Dosage regimen ( dose, frequency, route, formulation ) with severe hypokalaemia. In a UK hospital during the optimisation of electronic prescriptions: a direct observation study the optimisation of electronic:. And by cross-checking events are a serious public Health problem and a leading cause of in! Is illustrated in the treatment process is responsible for their part of process., definitions and functional meanings: when is enough enough a feedback form due to slips in attention occurred. 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