What to Do When You Make a Medication Error

It’s been more than 300 years since Alexander Pope wrote, “To err is human; to forgive divine.” Despite this human truth, no health care professional ever wants to be the one to make a mistake, and certainly no one wants to be the victim of a medical mistake.

As professionals in an industry where the slightest deviation from perfection can be deadly, what do we do if we make a clinical error? What are the essential steps to protect our patients and ourselves? How do we properly document and remedy the situation? And lastly, how can we learn from the error that occurred, or from the error that could have been so that these errors might never occur?

The initial fight-or-flight response we have when we realize we’ve made an error (or a “near miss,” which is an error that’s caught and corrected before it reaches the patient) is to somehow hide it or cover it up. This emotional, fear-based response is absolutely the wrong thing to do! Concealing an error may not only exacerbate potential harm to the patient by delaying appropriate care, but also prevent the organization from identifying and addressing system issues that can cause future errors.

As soon as you realize an event has occurred, immediate action and analytical thinking are necessary. It’s important to avoid blaming others for your mistakes because you may lose the loyalty and respect of your colleagues and coworkers. Your primary responsibility as a professional is to take care of the patient! Swift action is critical, so identify any actualized and potential adverse reactions as soon as possible to prevent any adverse effect from occurring or worsening.

There are 2 facets to consider when discussing a medical error with a patient. The “human” interaction you have (ie, bedside manner) can have a tremendous impact on how the patient perceives you and the event. This perception might influence the second facet—the legal implications of making a mistake. The legal aspect is beyond this article’s scope, and I’d advise you speak with a lawyer and consult your institution’s policy on what to do and what not to do in the event that legal action is taken.

However, in the past 30 years, much evidence has been built to support the advantages of disclosing errors to patients. Speaking with the patient and the family about an error has been shown to generally reduce the incidence of lawsuits. Nevertheless, be sure to follow your facility’s policy.

Once the patient is taken care of, report the error according to your organization’s policy. The most important thing to consider is that only the truth and the facts matter. Describe the who, what, where, how, and why of the event. Such details can help uncover whether any deviations from the normal operating process occurred, if there are any systems issues that may have contributed to the error, and how similar events can be prevented in the future.

The quality of an error report is only as good as the reporting system that guides the reporter through the documentation process. Robust error reporting systems are vital in highlighting the absolute essential details needed to describe an event. The purpose of a comprehensive reporting system is to effectively and efficiently collect important information, uncover patterns and trends within the data, prioritize the events in a manner that allows management to address the most significant errors and error types observed, and relay the information back from management to frontline personnel in a fashion that describes the lessons learned from all original reports submitted by the frontline personnel.

This entire process creates a complete circle that integrates staff from all levels and combines efforts into a singular and purposeful cause: to learn from medical errors. The best time to report an event is as soon as possible after the occurrence, and the best individual to report the event is the individual who was involved or who discovered or observed the event. Institutions should encourage all employees to report events and not assume the issue is already known to management. To accomplish this, health care administrators must gradually and continuously foster the proper patient safety culture so employees feel safe reporting medical errors.

Making a mistake is bad, but not confronting it is worse. Correct your error(s) by making sure minimal or no harm is done by addressing the problem right away. Once the error is under control, follow the policies of your organization so the error can be understood and learned from as a means of preventing a similar occurrence from happening in the future.

Lastly, don’t dwell on your mistake; just be sure to learn from it so that you don’t repeat it. Do everything in your power to right your wrong and then move on.