Prescription Pitfalls: Misprescription in Healthcare

Last Updated on February 29, 2024 by Laura Turner

Unfortunately, medical errors are a prominent issue in the healthcare community today. Medical errors are the third leading cause of death and, as of 2018, cause around 250,000 to 440,000 a year (Sipherd). Medical errors include a broad range of medical mishaps, but almost 50% involve misprescribing or misordering of medications (Dimetman). Providers throughout the healthcare system, including pharmacists and physicians, contribute to misprescribing and misordering errors. Despite the United States spending 17.3% (CMS) of national GDP on healthcare, the country holds the highest record for reported medical errors (Kermode-Scott).

With more action, medical errors could be one of the most preventable issues in the healthcare system. These types of errors not only cost billions of dollars to reverse, but they cause mental and physical health issues in patients, promote distrust in the healthcare system, and can often cause addiction and drug abuse. 

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The most obvious side effect of receiving an incorrect prescription is a physical reaction to an unneeded drug, which can sometimes lead to serious health conditions. Mixing different medications that are not meant to interact can cause unnecessary immune responses and also often lead to deadly side effects. Taking unneeded drugs can also cause major health conditions such as organ failure, change in personality and attitude, rapid heartbeat, and even death (Agency for Healthcare Research and Quality). Additionally, these physical effects can lead to mental health turmoil in patients, such as causing more pain in a patient needing to take pain medications or impacting a patient’s mobility. This type of unrest can cause stress and despair in patients and is overall detrimental to their mental well-being (Deeley).

Misprescribing: Higher Risk with Polypharmacy

An example provided in a study done by Nabhani Zadeh et al. discusses people with mental health disabilities who often take multiple medications at once; this is known as polypharmacy (taking more than five medications at once). Taking multiple medications at once can lead to dangerous drug interactions, increasing the risk of side effects and incorrect prescriptions (Nabhani Zadeh et al.). For example, a patient goes to the pharmacy to pick up the six medications they take for anxiety and PTSD. Every single time she picks up her medications or changes her medication, she is at a higher risk than others of medical errors. This is because dispensing locations can make more mistakes when there are multiple prescriptions to give and organize for one person.

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Impacts on Healthcare Providers and the Healthcare System

These mistakes not only cause mental issues within patients but can also hurt the healthcare professionals who made the mistake. Physicians can feel immense guilt, shame, and fear, which can lead to mental health disorders like depression (Deeley). Both healthcare professionals and patients are forced to face various struggles because of medical errors.

Consistent errors in the healthcare system will not only make healthcare professionals look less reliable and unprepared but also can lead to a lack of trust in the system as a whole. When a patient hears of or experiences a medical error firsthand, they inevitably feel fear and anxiety when it comes to trusting their physicians and dispensing professionals (Deeley). Medical errors cause immense side effects, and the fear of possibly experiencing one only grows as more medical errors occur. From a physician or healthcare professional standpoint, reporting these errors can cause detrimental consequences for their career. As a result, professionals often hesitate to report their errors or those of their colleagues (Rodziewicz et al.). This lack of transparency and honesty leads to a vicious cycle of recurrent medical errors that go unnoticed, leading to an unchanged and ineffective system. Once again, the consistent errors only make patients doubt and question the accuracy and credibility of healthcare professionals and their institutions. 

Mistakes Involving Controlled Substances

Substance abuse is a leading public health issue affecting teenagers and adults alike. Coincidentally, medical errors contribute to this issue, making it more possible for patients to accidentally get addicted to an incorrect medication. Drugs that are the most misused are opioids such as Oxycontin and those containing hydrocodone, anti-anxiety medications, and stimulants (Mayo Clinic). Opioids like oxycontin and ones containing hydrocodone are controlled substances, meaning they are stored in safes and require extensive pharmacist verification to fill because there is such a high potential for abuse. Prescribing these medications to the wrong person is putting them at a towering risk for abuse and addiction. In a study done in 2004, one in 12 patients were misprescribed. The rise in mis-prescriptions was correlated with higher rates of drug abuse (Modi). The study displays the direct effect of misprescribing drugs on the possibility of abuse and addiction.

Possible Solutions

Overall, the incorrect administration of medications can lead to lifelong consequences. The various impacts and effects of misprescription can be mitigated from two different facets: patient and professional. From a professional standpoint, structured and annual medication reviews in the pharmacy are proven to reduce medical errors (Nabhani Zadeh et al.). From the patient side, asking pharmacists, physicians, and other healthcare providers questions about their medication needs, duration, side effects, limitations, and dosage (Agency for Healthcare Research and Quality) can increase patient education and safety. Another solution from the patient side is to simply speak up; if there are any suspicious side effects or changes, let your prescriber know or ask a pharmacist (Agency for Healthcare Research and Quality). In summation, small revisions and practices can significantly reduce the frequency of medical errors.

Works Cited

“About CMS.” CMS, Accessed 29 January 2024.

Deeley, Elena. “How Medication Errors Can Affect Your Mental Health.” Psychreg, 24 December 2020, Accessed 29 January 2024.

Deeley, Elena. “How Medication Errors Can Affect Your Mental Health.” Psychreg, 24 December 2020, Accessed 29 January 2024.

Dimetman, Nicole. “35 Medical Malpractice Statistics for 2022.” Just Great Lawyers, 26 January 2022, Accessed 29 January 2024.

Kermode, Barbara. “US has most reports of medical errors.” NCBI, Accessed 29 January 2024.

Md, Sandeeb. “,.” , – YouTube, 21 October 2023, Accessed 29 January 2024.

“Medication Errors and Prescriptions: A Dangerous Trend.” Med League, 14 February 2011, Accessed 29 January 2024.

Nievas, Fernandez, and Virgilio S. HA. “Medication Dispensing Errors and Prevention – StatPearls.” NCBI, Accessed 29 January 2024.

“Prescription drug abuse – Symptoms and causes.” Mayo Clinic, 25 October 2022, Accessed 29 January 2024.

S, Acharya. “Medical Error Reduction and Prevention – StatPearls.” NCBI, Accessed 29 January 2024.

S, Acharya. “Medical Error Reduction and Prevention – StatPearls.” NCBI, Accessed 29 January 2024.

Sipherd, Ray. “Medical errors third-leading cause of death in America.” CNBC, 22 February 2018, Accessed 29 January 2024.

“Taking Medicines Safely as You Age | National Institute on Aging.” National Institute on Aging, 22 September 2022, Accessed 29 January 2024.

“20 Tips To Help Prevent Medical Errors: Patient Fact Sheet.” Agency for Healthcare Research and Quality, Accessed 29 January 2024.

“Wrong Medication Given.” Nursing Home Abuse Guide, Accessed 29 January 2024.

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