TABLE 1

Definitions and Examples of Medication Errors Identified in the Study

Error TypeDefinitionExample
Medication error with little potential for harmMedication error (ie, an error in medication ordering, transcription, administration, or monitoring) with little potential to cause harmOrder written for Tylenol with no route provided
Intercepted potential adverse drug eventMedication error with significant potential to cause harm but does not because it is intercepted before reaching the patientOrder for 30 mg of prednisone for wrong patient written by resident but intercepted by nurse
Nonintercepted potential adverse drug eventMedication error with significant potential to cause harm but does not because the patient has sufficient physiologic reserves to buffer the error without apparent injuryOrder written and drug administered for 10-fold overdose of enalapril, which was not discovered for several hours but caused no apparent harm
Preventable adverse drug eventInjury to a patient attributable to a medication errorFailure to monitor response to diuretic administration, which led to overdosing and consequent dehydration with hypotension