Medication Errors

• 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.