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Oregon Medication Data Form - Medication Error and Near Miss Classification
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Medication errors occur when weak medication systems and/or human factors such as fatigue, poor environmental conditions or staff shortages affect prescribing, transcribing, dispensing, administration and monitoring practices, which can then result in severe harm, disability and even death.
Medication errors can be classified, invoking psychological theory, as knowledge-based mistakes, rule-based mistakes, action-based slips, and memory-based lapses.
Table of Contents CategoryDescriptionANo error, capacity to cause errorBError that did not reach the patientCError that reached patient but unlikely to cause harm (omissions considered to reach patient)DError that reached the patient and could have necessitated monitoring and/or intervention to preclude harm5 more rows
Class C error or prohibited practice Type of action/inaction committed by staff that generally involves: ? The death of a person ? Injury requiring hospitalization or medical treatment at an emergency department, clinic or health care provider's office ? Falsification of records and/or certification paperwork ? ...
34.1 Category I An error occurred that may have contributed to or resulted in the patient's death. [ Classify each medication involved in a medication error. Include the intended product for use, as well as the actual product used, if these are different.
Common causes of medication error include incorrect diagnosis, prescribing errors, dose miscalculations, poor drug distribution practices, drug and drug device related problems, incorrect drug administration, failed communication and lack of patient education.
Near-misses can be classified as belonging to category B of the NCC MERP classification. Near-misses do not reach the patient, but can still potentially cause harm. In 1 emergency department, the rate of an error occurring but not reaching the patient was 11.8%.