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Rayhan A. Tariq; Rishik Vashisht; Ankur Sinha; Yevgeniya Scherbak.

Source: National Library of Medicine – www.ncbi.nlm.nih.gov/books/NBK519065

Last Update: July 3, 2022.

Close to 6,800 prescription medications and countless over-the-counter drugs are available in the United States. To further complicate a practitioner’s responsibility during patient care, there are thousands of health supplements, herbs, potions, and lotions used by the public regularly to treat their health problems. With the number of substances on the market, it is conceivable that mistakes can be made when practitioners prescribe or dispense drugs. Added to this is the high risk of interaction between substances.

Each year, in the United States alone, 7,000 to 9,000 people die due to a medication error. Additionally, hundreds of thousands of other patients experience but often do not report an adverse reaction or other complications related to a medication. The total cost of looking after patients with medication-associated errors exceeds $40 billion each year, with over 7 million patients affected. In addition to the monetary cost, patients experience psychological and physical pain and suffering as a result of medication errors. Finally, a major consequence of medication errors is that it leads to decreased patient satisfaction and a growing lack of trust in the healthcare system.[1][2]

The most common reasons for errors include failure to communicate drug orders, illegible handwriting, wrong drug selection chosen from a drop-down menu, confusion over similarly named drugs, confusion over similar packaging between products, or errors involving dosing units or weight. Medication errors may be due to human errors, but it often results from a flawed system with inadequate backup to detect mistakes.[3][4]

Objectives:

• Identify the most common errors related to medications.
• Review some of the critical points at which medication errors are most likely to occur.
• Outline some strategies to prevent medication errors from occurring.
• Summarize interprofessional team strategies for decreasing medication errors.

Issues of Concern

Medication errors are grouped by different taxonomies by the Joint Commission, World Health Organization, and The National Coordinating Council for Medication Error Reporting and Prevention.[20][21][22]

Some taxonomies consider the source of the error:

• Deteriorated drug error from compromised storage
• Drug utilization process errors from the administration, dispensing, or monitoring
• Prescribing errors

The most common system failures include:

• Inaccurate order transcription
• Drug knowledge dissemination
• Failing to obtain allergy history
• Incomplete order checking
• Mistakes the tracking of the medication orders
• Poor professional communication
• Unavailability or inaccurate patient information

The Agency for Healthcare Research and Quality, to better standardize medication reporting, developed the Common Formats, which are defined data elements collected and reported in the event of a medication error through the Patient Safety Organization Privacy Protection Center. The scope of the Common Formats encompasses all errors, including events that those that have the potential to affect the patient, near-misses, and those that have a patient effect.[23][24][25]

Full Article: https://www.ncbi.nlm.nih.gov/books/NBK519065/

Source: National Library of Medicine: https://www.ncbi.nlm.nih.gov/books/NBK519065/

Rayhan A. Tariq; Rishik Vashisht; Ankur Sinha; Yevgeniya Scherbak.

Author Information and Affiliations

July 3, 2022.

Medication Misadventure

A medication misadventure is an iatrogenic incident that is inherent to medication therapy. Medication misadventure includes medication errors, adverse drug reactions, and adverse drug events. It is created through omission or commission of medication administration. Medication misadventures always are undesirable and unexpected; they may or may not be independent of preexisting pathology; and might be due to human or system error, idiosyncratic, or immunologic response.[13][14][15]

Medication errors can occur at many steps in patient care, from ordering the medication to the time when the patient is administered the drug. In general, medication errors usually occur at one of these points:

• Ordering/prescribing
• Documenting
• Transcribing
• Dispensing
• Administering
• Monitoring

Medication errors are most common at the ordering or prescribing stage. Typical errors include the healthcare provider writing the wrong medication, the wrong route or dose, or the wrong frequency. These ordering errors account for almost 50% of medication errors. Data show that nurses and pharmacists identify anywhere from 30% to 70% of medication-ordering errors. It is obvious that medication errors are a pervasive problem, but the problem is preventable in most cases.[19]

Source: National Library of Medicine: https://www.ncbi.nlm.nih.gov/books/NBK519065/

Rayhan A. Tariq; Rishik Vashisht; Ankur Sinha; Yevgeniya Scherbak.

Author Information and Affiliations

July 3, 2022.

Causes of Medication Errors

Expired Product

Usually occurs due to improper storage of preparations resulting in deterioration or use of expired products.

Incorrect Duration

Duration errors occur when medication is received for a longer or shorter period of time than prescribed.

Incorrect Preparation

This error usually occurs with compounding or some other type of preparation before the final administration. An example is choosing the incorrect diluent to reconstitute.

Incorrect Strength

Incorrect strength may potentially occur at many points in the medication process. It usually occurs due to human error when similar bottles or syringes with the incorrect strength is selected.

Incorrect Rate

Most often occurs with medications that are given as IV push or infusions. This is particularly dangerous with many drugs and may result in significant adverse drug reactions. Examples include tachycardia due to rapid IV epinephrine or red man syndrome due to the rapid administration of vancomycin.

Incorrect Timing 

In both home and institutional settings, it is challenging to be completely accurate with scheduled doses. The concern is that some medication’s absorption is significantly altered if taken with or without food. As such, it is important to adhere to scheduled times as commonly; this may lead to under or overdosing.

Incorrect Dose

This error includes overdose, underdose, and an extra dose. An incorrect dose occurs when an inappropriate or different medication dose is given other than what was ordered, errors of omission when a scheduled dose of medication is not given, and when a drug is given via an incorrect route. Errors due to incorrect routes usually occur due to unclear labeling or tubing that is adaptive to multiple connectors/lines of access. Incorrect routes often result in result in significant morbidity and mortality.[26][27][28]

Incorrect Dosage Form

This occurs when a patient receives a dosage form different than prescribed, such as immediate-release instead of extended-release.

Incorrect Patient Action

This occurs when a patient takes a medication inappropriately. Patient education is the only way to prevent this type of error.

Known Allergen

Dispensing a drug that the patient has an allergy often due to failure to communicate with the patient, inappropriate chart review, inaccurate charting, or lack of technological interface.

Known Contraindication

This occurs when medications are not vigilantly reviewed for drug-drug, drug-disease, or drug-nutrient interactions.

Pharmacist

Errors by pharmacists are usually judgmental or mechanical. Judgmental errors include failure to detect drug interactions, inadequate drug utilization review, inappropriate screening, failure to counsel the patient appropriately, and inappropriate monitoring. A mechanical error is a mistake in dispensing or preparing a prescription, such as administering an incorrect drug or dose, giving improper directions, or dispensing the incorrect dose, quantity, or strength.

The most common causes involve workload, similar drug names, interruptions, lack of support staff, insufficient time to counsel patients, and illegible handwriting.

Distractions

One of the major causes of medication errors is distraction. Nearly 75% of medication errors have been attributed to this cause. Physicians have many duties in a hospital (e.g., examining patients, ordering laboratory and imaging studies, speaking to consultants, rounding on their patients, speaking to patient family members, conversing with insurance carriers before ordering studies), and in the midst of all this, they are often asked to write drug orders and prescriptions. In the rush to be done with writing drug orders, sometimes a lapse of judgment develops, and a medication error occurs. It can happen to the best physician. Sometimes the physician may be on the phone, and a clinician may be standing with the order chart next to him or her asking for a drug order. The physician may quickly scribble in a drug order, not paying attention to the dose or frequency. It is the unscheduled events in the life of a healthcare provider such as the constant pages, attendance at meetings, and answering telephone calls that disrupt patient care. Many physicians do not acknowledge that these distractions are a problem, but in reality, these distractions are often the cause of medication errors.[29]

To minimize distractions, hospitals have introduced measures to reduce medication errors. Most hospitals are working on ways to decrease distractions to ensure that medication orders do not occur. For example, physicians are urged to order drugs at a set time after rounding on their patients; this is when they also write their daily progress notes. Other clinicians are requested not to disturb the physician at this time of the day. Also, clinicians are asked only to disrupt the physician for an emergency. Physicians are being urged to develop a structure for their patient care that is organized so that distractions are limited. While answering a page is often necessary, many hospitals recommend that physicians not answer patient calls until patient duties are completed. Additionally, healthcare institutions are now penalizing physicians who continue to have too many medication errors because of distractions; the result is a restriction in prescribing privileges.

Of course, not all distractions can be eliminated because the practice of medicine is itself unpredictable and chaotic at the best of times.

Distortions

A prevalent cause of medication errors is distortions. The majority of distortions may originate from poor writing, misunderstood symbols, the use of abbreviations, or improper translation. A significant number of healthcare providers in the United States are from foreign countries and often write orders for medications that are not even available domestically. When a practitioner questions the drug, the physician often asks the nurse or pharmacist to substitute the medication prescribed for a similar drug. This type of distortion can lead to major errors because neither the non-prescribing practitioner nor the pharmacist can substitute a drug. All hospital pharmacies have a list of medications available in the formulary, and doctors should know what is available and limit the ordering from this list.

Illegible Writing

Illegible writing has plagued both nurses and pharmacists for decades. Physicians are often in a hurry and frequently scribble down orders that are not legible; this often results in major medication mistakes. Taking shortcuts in writing drug orders is a prescription for a lawsuit. Often the practitioner or the pharmacist is not able to read the order and makes their best guess. If the drug required is a dire emergency, this also adds more risk to the patient. To eliminate such errors, most hospitals have rules that practitioners and pharmacists have to follow; if the drug order is illegible, the physician must be called and asked to rewrite the order clearly. The practitioner or the pharmacist should never guess what the drug/dose is. The bad writing by physicians has become such a major problem that the Institute of Safe Medication Practices has recommended the complete elimination of handwritten orders and prescriptions. This problem has been resolved using electronic records where everything is typed, and poor writing is no longer an issue; however, errors still can occur from writing the wrong drug, dose, or frequency.[30][31]

Source: National Library of Medicine: https://www.ncbi.nlm.nih.gov/books/NBK519065/

Rayhan A. Tariq; Rishik Vashisht; Ankur Sinha; Yevgeniya Scherbak.

Author Information and Affiliations

July 3, 2022.

Types of Medication Errors

• Prescribing
• Omission
• Wrong time
• Unauthorized drug
• Improper dose
• Wrong dose prescription/wrong dose preparation
• Administration errors include the incorrect route of administration, giving the drug to the wrong patient, extra dose, or wrong rate
• Monitoring errors such as failing to take into account patient liver and renal function, failing to document allergy or potential for drug interaction
• Compliance errors such as not following protocol or rules established for dispensing and prescribing medications

Clinical Significance

Medication errors are a common issue in healthcare and cost billions of dollars nationwide while inflicting significant morbidity and mortality. While national attention has been paid to errors in medication dispensing issues, it remains a widespread problem. The best method to enhance patient safety is to develop a multi-faceted strategy for education and prevention. Emphasis should be put on healthcare providers working as a team and communicating as well as encouraging patients to be more informed about their medications. With a culture of safety, dispensing medication errors can be reduced.

• PMID: 28236867
• DOI: 10.1016/j.bjane.2015.09.006 

Medication Errors

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors’ are preventable.

In today’s world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to ‘treat’ drug errors is to prevent them.

Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively.

Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors.

The need of the hour is to stop the blame – game, accept mistakes and develop a safe and ‘just’ culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors.

• Medical Error is the third leading cause of death in the US. BMJ 2016;353;2139. Medical error also causes other injuries besides death.
• Medical error is also referred to medical negligence or medical malpractice and includes errors by all healthcare providers of any type e.g. doctors, nurses, physicians assistants, medical assistants, in all healthcare settings, e.g. offices, hospitals, surgery centers, nursing homes which produces injury of any kind.
• Death certificates do not list medical error as a cause of death–the problem is much bigger then reported. And, injuries e.g. loss of limb, loss of organ function are not reported or tracked statistically at all.
• Almost all medical malpractice happens ‘behind closed doors’. Patients are sick or may be under anesthesia or medicated and frequently do not know what happened. Family members are in the waiting room or not present or simply not told what happened with their loved one. What is worse is most states including Oklahoma have laws that protect physicians and hospitals from having to disclose the truth of what happened. These laws are called peer review laws. Peer review laws create a privilege, the privilege of secrecy, so physicians and hospitals do not have to disclose to the victim or their family members what happened or the outcome of an internal investigation.
• Frequently, patients or family members have to file lawsuits just to be able to find out what happened or how it happened. Knowing this information and understanding what and how the medical error occurred is important to the victim(s) to aid in coping mentally and emotionally with what has occurred. The victims need to know.