Medication error classification and prevention strategies in healthcare

Medication Errors

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Medication errors pose a significant threat to patients. The results of medication errors vary from mild to deadly. No facility is immune from the possibility to drug errors, either through a fault of their own, or from suppliers or pharmacists that supply them. All medication errors must be reported to the Food and Drug Administration. This agency keeps records of the types of drug errors that occur, with the intention of using them as a tool to improve patient safety on all levels (U.S. FDA). This study will explore many facets of medication errors and will present a review of a video on medication errors from the ISMP website. The purpose of this study is to gain a better understanding of medication errors and ways to minimize them in any medical setting.

A medication error is defined as an event that is preventable and that can cause inappropriate medication use for a patient while the medication in under the control of a health care professional (NCCMERP). Medication errors that are a result of patient error do not fall under the same category and are not tracked in the same manner as those caused by the medical facility. The medication error may or may not cause harm to the patient. However, any medication error has the potential to cause harm. Therefore, even medication errors that do not cause the patient harm are treated as seriously as those that result in consequences for the patient.

Types of Medication Errors

The American Hospital Association classifies errors according to several types depending on the root cause of the error. These include incomplete patient information, unavailable drug information, miscommunication of drug orders, poor handwriting, similar sounding name confusion, confusion of dosing units, inappropriate abbreviations, lack of appropriate labeling, and environmental factors (U.S. FDA). There are a number of classification schemes developed by other organizations, but the classification scheme developed by the American Hospital Association is the most widely used.

There are a number of common causes for each of the types listed above. For example, incomplete patient knowledge can mean unknown, or undisclosed allergies, other medications that the person is taking, unknown previous diagnoses, and unknown lab results. Unavailable drug information can mean a lack of up-to-date warnings and usage changes. Miscommunication is the widest of the medication error categories. This can result from poor handwriting, confusion between drugs with similar names. Sloppiness is the most common cause of miscommunication, such as inappropriate use of zeros and decimal points. Drug repackaging can mean the loss important labeling information. Environmental factors, such as interruptions, heat, poor lighting, too much noise and other distractions can also cause medical errors.

Video Summary and Response: Transdermal Patches with Metallic Backings

In March of 2009, the FDA notified the public that certain transdermal patches contained aluminum or other metals in the backing. These patches are applied to the skin and the medication dose is absorbed through the skin. The metals on these transdermal patches can overheat during an MRI scan, causing skin burns to the area of the patch. The FDA is considering changing labeling on the patches to reflect this danger. However, the MRI technician also has a responsibility to make certain that the patient is not wearing a transdermal patch prior to an MRI scan.

This video demonstrates the multiple layers that must come into play in regards to medication errors. The blame and responsibility cannot be placed on a single person. There are many levels of patient contact, from package labeling to the technician who will perform the scan. This also means that multiple layers of protection should be put in place as well.

Preventing medication errors is everyone's responsibility. A multi-layered approach must be taken to this multi-layered problem. The most important fact in medical errors is that they are completely preventable. However, no single method provides the ultimate answer to the problem. Systems must be put in place on every level of the system. However, systems will not be 100% effective without a commitment to preventing medical errors from the staff.

Everyone must hold themselves personally accountable for preventing medication errors. Systems and technological devices can only go so far in eliminating certain types of medical errors. When one examines the root of the problem, they will find a human at the end of every error, a human that should have intervened to prevent the problem. Personal accountability must be ingrained into healthcare professional and become a part of institutional culture. This is the only way to have a true impact on the reduction of medication errors in the healthcare setting.