Medication Errors Associated with the Use of Penicillins

Clinical Microbiology and Antimicrobial Chemotherapy. 2016; 18(2):93-103

Journal article


To determine the prevalence of medication errors associated with the use of penicillin-group antibiotics through analysis of national spontaneous reporting database.

Materials and Methods.

The study involved examination of 1123 spontaneous reports about adverse drug reactions related to penicillin-group antibiotics. All these reports were sent to Russian safety database in the period from 01.01.2012 till 01.08.2014. To identify cases of medication errors we used Russian drug labels, standards of medical care and practical guidelines for certain diseases.


Medication errors were detected for 36,9% of all spontaneous reports. In 17% of these cases two or more errors were made. One third (32.9%) of all medication errors included different deviations from the recommended dosage regimen. An indication was absent or inappropriate in 29,8% cases of incorrect use of antibiotics. 13.0% medication errors were associated with the cases where the antibacterial drug was prescribed to a patient, who had contraindications to it, in most cases (92%) — to a patient with hypersensitivity to penicillin or to other beta-lactams. The most commonly used drugs, amoxicillin and amoxicillin/clavulanic acid, have the highest prevalence of medication errors — 41% and 40% respectively.


The results of this study demonstrate a high rate of medication errors associated with the use of penicillin-group antibiotics. A range of different measures are recommended for error reduction: to follow an appropriate dosage regimen, to avoid prescribing antibiotics for treatment of viral infections, to collect drug anamnesis accurately, considering cross-hypersensitivity reactions.

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