Medication errors can occur when one of the five rights goes wrong the wrong medication is dispensed, the wrong patient receives a medication, or a patient receives a medication at the wrong time, by the wrong route, or in the wrong dosage. Mistakes can occur anywhere from the physician's handwriting to the pharmacy to the administering nurse. Vigilance is essential.
Communication problems are another common source of errors.
Health care providers must communicate critical patient information to one another including lab values, allergies, drug contradictions, and diagnoses. Miscommunication causes errors in the form of poorly handwritten orders, confusion of drugs with similar names, careless use of zeros and decimal points, inappropriate abbreviations, ambiguous or incomplete orders, and even disagreements between practitioners. In 1998, the President's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry was created. Also in 1998, the National Roundtable on Healthcare Quality and the IOM began their work. In 1999, both the Medicare Payment Advisory Commission and the Committee on Quality of Healthcare in America focused on quality issues.