An adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication. 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). Appropriate prescribing in elderly people: how well can it be measured and optimised? 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). I therefore prefer to use the terms ‘prescribing faults’ and ‘prescription errors’.9 The term ‘prescribing errors’ ambiguously encompasses both types. The administration of medications are primarily the nurse’s responsibility, on which spend up to 40% of their time on administering medications [ 4 ]. 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… 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. ), and Rule Title 64B24, Florida Administrative Code. Her doctor reasoned as follows: – spironolactone is a potassium-sparing drug; – spironolactone will cause her to retain potassium; – her serum potassium concentration will normalize. 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. 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. Wrong label information and instructions were the most common types of errors. A Venn diagram showing the relation among adverse events, ADRs and medication errors; the sizes of the boxes do not reflect the relative frequencies of the events illustrated (Reproduced from reference 8, with permission from Wolters Kluwer Health/Adis ©; Adis Data Information BV (2006); all rights reserved). Modal classification examines the ways in which errors occur (for example, by omission, repetition or substitution). 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 Greek poet Archilochus (seventh century BC) wrote that ‘The fox knows many things, the hedgehog one big thing’. 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. 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