The American Society of Hospital Pharmacists (ASHP) have identified risk factors predisposing to medication errors. A health care facility trying to eliminate medication errors need to target these problem areas.


(1) confusing drug product nomenclature, packaging or labeling

(a) ambiguous strength designation on labels or in packaging

(b)) drug product nomenclature (look-alike or sound-alike names; use of lettered or numbered prefixes and suffixes in drug names)

(2) dosage forms

(3) drug category (high risk or problem prone)



(1) equipment failure or malfunction

(2) medication unavailable

(3) medication out of date

(4) improper drug storage

(5) improper drug preparation or dispensing

(6) distribution system (unit dosing preferred)

(7) labeling errors



(1) illegible handwriting

(2) improper transcription

(3) inappropriate abbreviations used in prescribing

(4) verbal (orally communicated) orders

(5) inaccurate dosage calculation

(6) poor communications


Personnel related (may affected pharmacy, nursing or other health care providers:

(1) inexperienced and/or inadequately trained personnel

(2 excessive workload and fatigue

(3) lapses in individual performance

(4) environmental factors (lighting, noise, interruptions)

(5) work shift related, including weekends and holidays



(1) populations with special needs

(2) increased number or quantity of medications per patient



(1) timing of doses

(2) omission (forgetting to give)

(3) route of administration

(4) documentation of administration



(1) patient monitoring

(2) drug level monitoring

(3) disease response



(1) lack of effective policies and procedures

(2) poorly functioning oversight committees (and management)

(3) inadequate performance review

(4) lack of effective problem reporting and handling mechanism

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