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Study Shows Administration Errors Top Reason for Medication Mix Ups

Sadly, medication mix-ups are among those on the long list of medical errors that result in injury or death to many patients every year in the United States.

Physicians with poor penmanship who write prescriptions that pharmacists are unable to read properly or incorrect medication that is dispensed because of its similar name to another prescription are a couple of examples.

However, data from a study conducted by the Pennsylvania Patient Safety Authority sheds light on the main reasons why medical errors from medications occur.

Administration Errors Top Cause of Errors

The Pennsylvania Patient Safety Authority, an independent state agency that takes steps to help reduce medical errors, examined over 800 instances that involved patients who received the wrong medication. The results showed that 43 percent of the total instances were due to some type of administrative error.

Specifically, the data showed that nurses or other hospital personnel dispensed the medication to the wrong patient because they failed to follow proper procedures to identify the patient.

For instance, today, many instances, hospitals or healthcare entities ask the patient or his or her family member to confirm his or her date of birth before handing over the medication in order to make sure the right patient is getting the right prescription.

In healthcare settings where nurses care for dozens of patients simultaneously, researchers from the study determined that the personnel were failing to confirm this information and thereby getting the patients confused.

Transcription Errors Take Second Place

Researchers determined that transcription errors were the second biggest reason for medication mix-ups. (Transcription involves the transferring of information or medication prescription provided by the physician by a nurse or hospital personnel to a patient’s file or medical record.)

Approximately 38 percent of the total instances were due to a transcription errors.

The data from the study showed that the staff was transferring patient information, including the recommended medication, to the wrong patient chart.


According to researchers, these types of errors can be reduced, or even eliminated if small procedural changes were implemented in healthcare settings.

Mandatory confirmation of a patient’s identify-even more than once-before any procedure or mediation is provided can reduce medication errors. A nurse can ask the patient to provide his or her name and DOB, and then double check the attached ID bracelet, for example, to make sure the right patient is receiving the right prescription.

Also, computer systems that allow personnel to access only one electronic medical record at one time can also decrease the chance that the wrong information is entered into the wrong patient’s record.