Source: National Library of Medicine: https://www.ncbi.nlm.nih.gov/books/NBK519065/

Rayhan A. Tariq; Rishik Vashisht; Ankur Sinha; Yevgeniya Scherbak.

July 3, 2022.

Medication Misadventure

A medication misadventure is an iatrogenic incident that is inherent to medication therapy. Medication misadventure includes medication errors, adverse drug reactions, and adverse drug events. It is created through omission or commission of medication administration. Medication misadventures always are undesirable and unexpected; they may or may not be independent of preexisting pathology; and might be due to human or system error, idiosyncratic, or immunologic response.

Medication errors can occur at many steps in patient care, from ordering the medication to the time when the patient is administered the drug. In general, medication errors usually occur at one of these points:

  • Ordering/prescribing
  • Documenting
  • Transcribing
  • Dispensing
  • Administering
  • Monitoring

Medication errors are most common at the ordering or prescribing stage. Typical errors include the healthcare provider writing the wrong medication, the wrong route or dose, or the wrong frequency. These ordering errors account for almost 50% of medication errors. Data show that nurses and pharmacists identify anywhere from 30% to 70% of medication-ordering errors. It is obvious that medication errors are a pervasive problem, but the problem is preventable in most cases.

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