Medication Errors

Guest Blogger: Neveen Eed, PharmD Candidate 2015, MK Education Intern

National Coordinating Council for Medication Error Reporting and Prevention categorized the different types of error according to the extent of harm they cause. This categorization is known as MERP index.

Medication errors do not only result in patient injuries, but also are one of the reasons behind prolonged hospitalization and result in increasing healthcare costs of about 3.5 billion dollars according to 2006 statistics. Out of 1.5 million yearly medication errors 100,000 patients die. Many of these adverse drug events are preventable and could be eliminated. Below is a non-inclusive list of consequences to medication errors:

• Death

• Permanent harm to patients

• Temporary patient harm and/or prolonged hospitalization

• Decreased staff morale

• Increased costs to patients and healthcare

• Loss of trust and credibility

Errors can happen at any point of the medication processing steps, it can happen while prescribing, and it also can happen while administration, and in any step in between, as well as technical errors. All healthcare professionals have to be careful and double check their work to assure that the right drug is given to the right patient at the right time and with the right strength and dosage form. They also have to be extra careful with sound alike and look alike medications because these medications tend cause a lot of errors especially at the transcribing and filling steps.

The USP website posted a scenario involving a medication error that happened at a hospital. The physician prescribed Lasix 40 mg, which is diuretic that is, used for congestive heart failure. The medication is stored in an automated dispensing cabinet (ADC) as 20 mg tablets. The nurse opened the correct drawer by selecting the correct medication and took 2 tablets out and gave them to the patient without checking the label. It turns out that the medication the nurse gave to the patient was Lanoxin 0.25 mg, which is a glycoside for atrial fibrillation and heart failure. The pharmacy technician who filled the ADC earlier had incorrectly put the wrong medication in the ADC drawer. Even though the patient is already on Lanoxin 0.25 mg once daily, receiving 2 tablets by mistake makes that triple the correct dose he should be receiving. As a result, the patient developed bradycardia and became nauseated. This problem could’ve been prevented with the nurse checking the label on the medication when she pulled the drug out of the drawer or when she gave it to the patient. Also, it could’ve been prevented if the pharmacy technician was more careful while filling the drug in the ADC.

Patient’s safety and care is the first priority in any healthcare institution. Therefore, it is the responsibility of healthcare professionals to insure that the optimal care is delivered to each patient. There should always be safety checks in place at every step of the medication route to the patient. All healthcare workers need to realize and understand why the safety checks are in place and not get complacent or offended by them and follow through each and every time.

Sources:

Preventing medication errors Chapter 9http://cengagesites.com/academic/assets/sites/5242/9781439058473_ch09.pdf (Accessed 8/10/2014)

Medication errors stats examples http://www.alcooklaw.com/practice-areas/medication-error-injury/medication-error-stats-examples/ (accessed 8/8/2014)

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