The Genesis of Medication Errors

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Chapter: Pharmacovigilance: Fatal Medication Errors and Adverse Drug Reactions - Coroners’ Inquests and Other Sources

Errors can be classified into two broad categories: ‘mistakes’ and ‘slips or lapses’.


Errors can be classified into two broad categories: ‘mistakes’ and ‘slips or lapses’. The former occur when something is wrong with the premise on which an action is based. For example, the action in case 3, when the patient was given a dose of tuberculin PPD intradermally that was appropriate for a multiple punc-ture, represents a mistake. This was an error in the planning of an action as the junior doctor was not aware of the difference dosage requirements needed for the two methods of conducting a tuberculosis test. By contrast, Case 2, in which a momentary lapse of attention led to air, instead of contrast medium, being injected into a patient’s carotid artery illustrates a slip, which is an error of the second sort, occurring during the execution of a planned action (Reason, 1990). To some extent, training and education will help to over-come mistakes, but it is difficult to prevent slips and lapses by training, because they represent defects in tasks that are not under conscious control.

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