medication errors

Objectives

• Define the term "medication error" and describe the frequency of different types of errors.

• Build upon the basic understanding of the medication verification process and understand the steps taken to prevent medication errors.

• Practice the verification process and identify medication errors.

Medical Errors and Case Studies

• Emily Jerry Story: Details the tragic outcome of a medication error involving a child. Visit the Emily Jerry Foundation for more information.

• Case Studies:

  • Josie's Story: Died from severe dehydration and misuse of narcotics (2001).

  • Dennis Quaid's Twins: Experienced an overdose of Heparin (2007).

  • New England Compounding Center: Linked to a meningitis outbreak (2012) resulting in 44 deaths across 23 states.

  • A patient in West Virginia prescribed Lamictal® received a different drug, lomustine, improperly dispensed by the community pharmacist.

  • A fatal dose of vecuronium was administered instead of the sedative Versed by a nurse at Vanderbilt, leading to legal consequences (2022).

  • Two hospitals in California cited for dispensing errors (2023), including giving two doses of Lovenox® too close together and misdosing blood pressure medicine.

Defining Medication Errors

• According to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP):

  • Definition: A medication error is a preventable event leading to inappropriate medication use or patient harm during the medication's control by healthcare professionals or patients.

  • Related Factors: These may include prescribing, order communication, product labeling, compounding, dispensing, administration, education, and monitoring.

Statistics on Medication Errors

• Setting Frequency:

  • 61% occur in inpatient settings; 39% in outpatient settings.

• Categorization of Errors:

  • Ordering/Prescribing: 53%

  • Administering: 13%

  • Monitoring: 13%

  • Dispensing: 10%

  • Documenting: 7%

  • Miscellaneous: 4%

  • Source: Kuo GM et al., Pharmacotherapy, 2013.

The Scale of Errors

• If a pharmacy fills 350 prescriptions daily, approximately 7 could be incorrect, totaling around 51.5 million errors annually.

• Annual Errors:

  • 1.5 million medication errors reported.

  • Rates increased from 1.09 per 100,000 in 2000 to 2.28 in 2012.

  • Reference: Hong K, Research in Social and Administrative Pharmacy, 2018.

Factors Contributing to Errors

• Elements implicated:

  • Incomplete patient information (e.g., missing allergies).

  • Drug information issues.

  • Communication failures regarding medications.

  • Drug labeling and storage.

  • Staff competency and education deficits.

  • Quality processes and risk management.

  • Reference: Cohen, Michael R, 2007.

Common Medication Errors

• Types:

  • Incorrect medication,

  • Wrong dosage strength or form,

  • Wrong route of administration,

  • Wrong frequency,

  • Dose miscalculations,

  • Failing to identify drug interactions,

  • Incorrect patient.

• These errors represent nearly 50% of medication errors.

  • Source: Cohen, 2007; Wheeler et al., 2018.

Pharmacist Errors

• Mechanical Errors:

  • Wrong drug, dosage form, directions, quantity, or strength.

• Judgmental Errors:

  • Improper counseling, failure to detect interactions, neglecting to collect allergy history, inadequate drug review, and poor supervision of staff.

Medication Error Categorization

• Categories of Error (NCC MERP):

  • Category A: Circumstances that could cause an error.

  • Category B: Errors that did not reach the patient.

  • Category C: Errors that reached the patient but did not harm.

  • Category D: Errors needing monitoring to confirm no harm occurred.

  • Category E: Temporary harm required intervention.

  • Category F: Temporary harm with prolonged hospitalization.

  • Category G: Permanent patient harm.

  • Category H: Contributed to patient death.

Consequences of Medication Errors

• Significant impact:

  • 44,000-98,000 hospital deaths annually due to errors.

  • Outpatient errors costing the U.S. healthcare system $4.2 billion annually.

  • Global costs of medication errors range from $37.6 billion to $50 billion yearly.

Recommendations for Improving Medication Management

• Institute of Medicine (IOM) Suggestions:

  • Enhance communication between healthcare professionals and patients.

  • Develop consumer-friendly drug information resources.

  • Transition all prescriptions to electronic format.

  • Improve drug naming, labeling, and packaging to reduce errors.

Systems to Prevent Errors

• The Joint Commission oversees hospital settings.

• There is a lack of oversight for community pharmacies, indicating a need for further research.

Reporting of Errors

• Reporting is not mandated in most states.

• FDA and ISMP websites provide resources for reporting errors and obtaining information.

Tips for Prescription Verification

• Have patients actively state important details:

  • Patient's name, DOB, drug name, strength, directions, quantity, refills, prescriber information, and DEA number where necessary.

Pharmacist's Role in Error Prevention

• Clarify any prescription details with physicians if there are questions.

• Carry out thorough checks on prescriptions.

• Ensure personal wellness to decrease the likelihood of errors.

Best Practices to Decrease Errors

• Avoid using abbreviations in practices.

• Always clarify prescriptions when in doubt.

• Regularly update patient profiles and engage in experiential learning.

• Maintain a humble approach; ask questions and seek guidance.

Additional Resources and Assignments

• Explore more medication error case stories through provided video links and articles.

• Complete a prescription creation assignment which includes identifying a medication error.