Common Drug Safety Mistakes Put Your Healthcare at Risk?

introduction

.Every year, thousands of individuals suffer from preventable pharmaceutical errors, improper prescription usage, or harmful drug combinations.Therefore, to prevent drug safety mistakes, it is crucial to realize how they occur.
These mistakes can happen to anyone, including children, adults, and elderly patients, and are not limited to individuals with complicated prescriptions. Preventing medication safety mistakes begins with underastanding what these mistakes are, when they occurs, and how they impact your health. Drug safety mistakes can be fatal and are not just administration faults

Drug safety mistakes are avoidable incidents that could result in improper use of drugs or patient injury. Specifically, these can happen during the prescription, compounding transcription, dispensing, administering, or monitoring phases of the drug procedure.
For example, typical instances include failing to disclose drug sensitivities, administering the incorrect medication, delivering the incorrect dosage, and experiencing drug interactions. This type of mistake can lead to severe health impairments, which, in turn, can either lead to long stays in a hospital or even to death. Enforcing safety measures, employing electronic systems to prescribe medication, and enhancing information sharing among the medical professionals are essential to decreasing the possibility of these preventable injuries.

A tragic example report in 2006 of Emily Jerry a 2 year child who received chemotherapy prepared bag a 26 time concentrated normal saline than normal concentration consequently, this concentration caused her death. This unfortunate result demonstrates how easy errors in drugs safety mistakes

During Prescribing; How error can occur?

During Prescribing, mistakes may occur when a medical professional chooses an incorrect medication, sets an improper dose, or neglects relevant patient factors such as allergies or liver/kidney dysfunction.
Prescription safety protocols are crucial at this point, but they are frequently ignored, which leads to preventable errors. Such miscommunications or incomplete medical records are likely to cause these errors. An example involves a patient being allergic to penicillin who has been exposed to amoxicillin, whose use leads to anaphylaxis. All these kinds of prescribing errors caused by allergies are the most common and avoidable medication errors

son, 2006).

Within Pharmacy during Dispensing can happen

A dispensing mistake occurs when the pharmacists state the wrong medication or the incorrect dose of medication, which usually results when pharmacists mix up medicines with similar names or have illegible writing on the prescription.

As an example, a documented risk is confusing chlorpromazine (an antipsychotic) with chlorpropamide (a diabetes drug) that have look-alike, sound-alike (LASA) drug names. These medications are considered a part of the list of commonly confused drugs identified by the Institute for Safe Medication Practices.( (ISMP, 2022).ISMP, 2022

 At Home risk of improper drug administration

Administration errors at home might include the wrong dose, skipping a dose, or interactions of drugs that are harmful. Such mistakes usually happen when a person lacks awareness, labeling, or direction. According to the study Yin et al,(2014) Parents usually make medication mistakes. Approximately 4 out of 10 parents administered the incorrect amount of medicine during medication measurement or following the prescribed dose. Almost 17 percent used unmeasuring medicine facilities such as kitchen spoons.

Parents who used teaspoons or tablespoons were twice as likely to make mistakes with their measures as those who used milliliters (mL). Parents with inadequate health literacy or whose communication language was not English were even more at risk of making a mistake. Nonstandard measurement instruments, including home spoons, were likely the origin of these measurement mistakes.

Common Drug Safety Mistakes and Their Risks

Taking the Wrong Dose

There is a risk to health when the dose is wrong because of taking too little or too much of the medicine. There is a possibility of overdose that can result in toxicity and underdose, which can render the treatment ineffective. According to Tanne ,(2006), overdose of paracetamol is one of the common causes of acute liver failure in the UK and the USA.

 Mixing Drugs Without Understanding Interactions

Interaction of prescription drugs and over-the-counter (OTC) medications or herb supplements can have adverse effects when taken together without a physician advising .For example serious bleeding can happen if you take warfarin, a blood thinner, with aspirin or herbal supplements like ginkgo biloba. A lot of patients are not aware of this relationship (NHS,2022).

Not Following Instructions

Neglecting the instructions in the package, like taking it with food or taking it without crushing or chewing, can serve to undermine effectiveness or harm the person taking it.

For example, a case report is that a patient was a 38-year-old female who was hospitalised with acute pulmonary oedema and pneumonia, where she received crushed prolonged-release nifedipine (XL) and labetalol through a nasogastric tube. The breakdown of the nifedipine tablet by crushing broke the effect of slow-release, and the very quick release of drugs resulted in moderate hypotension and at least bradycardia. Labetalol also inhibited the compensation of her heart rate. She had two asystolic arrests, with the latter being fatal. There is an issue of tolerability and danger of crushing controlled-release drugs; better healthcare communication and administration are noted by the case.(Schier et al., 2003).

 Incorrect Medication Use by Elderly Patients

The risk of confusion, missing doses, or unintentional overdose is increased among older persons who often take many medications (polypharmacy). The elderly patients are more vulnerable to adverse drugs reaction (ADRs) caused by age-induced changes in metabolism and the high probability of drug safety errors when treating many medications.

Actual Case: A woman, aged 85 years that was taking multiple long-term medications received a propranolol, tramadol and paracetamol and experienced a diffused skin reaction. Corticosteroids in oral form were used to treat the reaction along with the removal of other unwanted medications. The steroids played the reverse of the adverse reaction although they are risky. The patient got well with proper observation. The case indicates the risks of polypharmacy and the necessity of drug review among the elderly patients (Nechba et al,2015).(Nechba et a2015).

How Do These drug safety Mistakes Impact Your Health?

Drug safety mistakes can result in:

• Adverse Drug Reactions (ADRs)
• Hospitalizations
• Loss of trust in healthcare
• Long-term health damage
• In severe cases, coma ,ventilated or death can occur

A report in BMJ Quality & Safety estimated that 237 million medication errors occur yearly in England alone, contributing to 1700 deaths and costing the NHS £98 million annually (Elliott et al., 2021).

Vulnerable Groups Most at Risk

Children: Dosing mistakes due to body weight  calculations

Elderly: Cognitive decline and Confusion from polypharmacy

Pregnant women: Due to Teratogenic drug risks or further problem may occur in embryo.

Patients with chronic diseases: Complex regimens increase the chance of mistakes

Preventing Drug Safety Mistakes

Understand Your Medications

Ask your genera physician or pharmacist about:

• What the medication is for and why you recommended this medicine
• When and how to take it
• Possible side effects adverse effect and interactions with another drugs or food

Keep an Updated Medication List

Maintain and have a list of Medications thatr you are taking. You should always have a record of all your medications i.e. prescription drugs, over-the-counter drugs, supplements, as well as herbal medicines. You should give this list to all of your healthcare providers.

Use Correct Measuring Tools

Never use kitchen spoons to measure medication prescribed since they are very inaccurate; always utilize the dosing tool that is supplied with the medication (e.g., dosing cup and oral syringe). This is particularly necessary in administering medicine to children.

Store Medicines according to instructions

Medicines should be kept in their own medicine bottles and stored at a cool and dry place or some medicine kept in fridge so follow instruction according to label. Medicine should be inaccessible to children and animals. Ensure expiry dates used, replace any unwanted or expired medications safely.

Check Labels and Instructions

Read the label carefully each time before taking a prescription. Follow the instruction available on medicine and do not share your prescription ‘s medicine to other one. Always double-check the dosage and dosage to avoid common drug safety mistakes.

Use or Apps and Pill Organisers

For those taking multiple drugs medication reminder apps can reduce confusion .and also use tools like pill organiser.

Ask question if you have any confusion

When you experience side effects, when you feel uncertain about what prescription drugs you are taking, when you feel that there is something wrong, you should not be afraid to ask questions. Seek the advice of your physician or Pharmacy.

What Should You Do If a Mistake Happens?.

• Stay calm – don’t panic because it will make worse the situation.
• Contact to a General Physician, a pharmacist, or NHS 111 in the UK.
• Share all information such as Name of drug, amount consumed sign and the symptoms.
• SaveContact to a General Physician, a pharmacist, or NHS 111 in the UK. receipt that will helps in identification and inspection.
  

Final Thoughts

Errors relating to drug safety are avoidable and their neglect can be disastrous. Regardless of whether you or your loved one are using medicines, being aware, alert, and communicative may help with reducing the risks considerably.

Conclusion

If you’ve experienced a drug safety mistake or want guidance on managing your medications, Consult your doctor or pharmacist.
Your safety matters—ask questions, stay informed, and report any issues. Implementing checks and balances is also crucial for healthcare systems in order to lower prescription errors and advance patient safety .By asking the right questions and staying informed you can avoid drug safety mistakes that put your health at serious risk.

Key points

• Although drug safetly errors are frequent, they can be avoided with the right knowledge and attention.
• Medication Errors may arise when prescribing, dispensing, or using at home.
• Drug interactions, incorrect dosages, and noncompliance with directions are common mistakes.
• Medication errors are more likely to happen to children and the elderly so need extra precaution.
• Cases from real life demonstrate the grave repercussions of medication errors.
• Safety precautions involving prescription medications include labels, reading and inquiry on the usage of new drugs.”
• Understanding your medications, utilizing the right equipment, storing them safely, and doing routine evaluations are all preventative measures.
• The secret to being safe is to be knowledgeable and to ask questions.

Frequently Asked Questions (FAQ) About Drug Safety

What are three rules to use for your safety when taking medications?

• Know Your Medicine: Know its purpose, dosage, and potential adverse effects.
• Follow instructions carefully. At the appropriate time, take the appropriate dosage.
• Ask Before Mixing: Before consuming alcohol, vitamins, or other medications, consult your physician or pharmacist.

What are some good question which should ask to pharmacist?

The good question which everyone should know or ask to Physician or Pharmacist
What is the use of this medicine?
How do I take the recommended medicine?
What are the dose and duration gap between the next dose?
what happen if I missed the dose,any possible side effect?
Does it interact it food ,alcohol, OTC medicine or dietary supplement?
How to store this drug properly
Is there a generic for affordability options?
Do I need a follow up?

Which of the following is a key challenge in drug safety monitoring?
Identifying uncommon or delayed adverse medication reactions is a major difficulty in drug safety monitoring. These are frequently underreported after marketing and overlooked in clinical trials.

What are the 5 drug safety checks for its administration?

The 5 drug safety checks of medication administration are:

1. Right patient- Authenticate the identity of the patient to prevent the problem.

2. Right Drug-This means that the correct drug should be administered.

3. Right dosage -Take the necessary dosage carefully.

4. Right route- Administration route (oral, IV, etc.) is the correct one.

5. Right time -Administer the drug at the right time so as to remain effective and harmless.

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Emily Jerry Foundation. (n.d.). Emily’s story. Emily Jerry Foundation. Retrieved August 6, 2025, from https://emilyjerryfoundation.org/emilys-story/
Ferner, R. E., & Aronson, J. K. (2006). Clarification of terminology in medication errors: Definitions and classification. Drug Safety, 29(11), 1011–1022. https://doi.org/10.2165/00002018-200629110-00001

Institute for Safe Medication Practices. (2015, February). ISMP’s list of confused drug names [PDF]. ISMP. Retrieved August 6, 2025, from https://www.ismp.org/sites/default/files/attachments/2017-11/confuseddrugnames%2802.2015%29.pdf

NHS. (n.d.). Taking warfarin with other medicines and herbal supplements. NHS. https://www.nhs.uk/medicines/warfarin/taking-warfarin-with-other-medicines-and-herbal-supplements/

Schier, J. G., Howland, M. A., Hoffman, R. S., & Nelson, L. S. (2003). Fatality from administration of labetalol and crushed extended-release nifedipine. Annals of Pharmacotherapy, 37(10), 1420–1423. https://doi.org/10.1345/aph.1D020

Tanne, J. (2006). Paracetamol causes most liver failure in UK and US. BMJ, 332(7542), 628. https://doi.org/10.1136/bmj.332.7542.628
Yin, H. S., Dreyer, B. P., Ugboaja, D. C., Sanchez, D. C., Paul, I. M., Moreira, H. A., Rodriguez, L., & Mendelsohn, A. L. (2014). Unit of measurement used and parent medication dosing errors. Pediatrics, 134(2), e354–e361. https://doi.org/10.1542/peds.2014-0395