Top 10 medication hazards of 2019 include selecting wrong drug on computer screens

photo shows torso of hospital doctor in hallway holding tablet computer
Providers need to be careful selecting medications on their computer screens and tablets to avoid errors, the Institute for Safe Medication Practices said. (Sergey Tinyakov/GettyImages)

Providers are making an increasing number of mistakes selecting the wrong medication for patients on their computer screens or tablets, according to the Institute for Safe Medication Practices (ISMP).

The problem is that physicians and other providers select the wrong medication after entering the first few letters of the drug name into their technology screens, said the institute, which released its list of the top 10 most persistent medication errors and hazards it uncovered in 2019.

Entering just the first few letters of a drug name or combination of the first few letters and product strength can allow the presentation of similar-looking drug names on computer screens, leading to selection errors, the institute said.


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“This is a problem that has increased in frequency with the upswing in technology use. In fact, wrong selection errors may now rival or exceed those made with handwritten orders,” the institute said.

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Reflecting on the 20-year anniversary of the landmark Institute of Medicine report To Err Is Human, which put a spotlight on medical errors and the need to improve patient safety, the institute published a top 10 list of errors and hazards that it covered in its newsletter in 2019.

The list focuses on safety problems that are frequently reported, caused serious harm to patients, and could be avoided or minimized with system and practice changes attainable by all healthcare providers, the institute said. The list appears in the January 16 issue of the ISMP Medication Safety Alert Acute Care newsletter.

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ISMP’s top 10 list included the following other common problems:

  • Prescribers inadvertently prescribing oral methotrexate for non-oncologic conditions daily when weekly administration was intended.
  • Errors resulting from lookalike labeling of manufacturer’s products.
  • Misheard drug orders or recommendations during verbal/telephone communications.
  • Unsafe “overrides” with automated dispensing cabinets.
  • Unsafe practices associated with IV push medications.