Medication errors in clinical practice and patient safety

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.

Methods of Prevention

The focus of recent research in the area of medical errors has been on preventing them, regardless of the cause. Root cause analysis is the most common type of error prevention being used. Root cause analysis addresses the reason for the error, regardless of the outcome and attempts to devise a way to eliminate that specific cause (Griedman, Geoghegan, Sowers, Kulkarni, and Formica). The source to some medication errors is equipment failure, such as failure of a timing device or dosage device. However, a majority of the errors are human in nature.

In a recent study, it was found that a computerized physician order entry system significantly reduced the number of medication errors in the pediatric unit of a community hospital (Wang, Herzog, and Kaushal et al.). The most dramatic effect of this system was communication errors, such as those associated with physician handwriting. The computer system was able to intercept many potentially dangerous medication errors. Computers and improved policies and procedures will help to eliminate a majority of medication errors in the clinical setting.

The medication reconciliation process involves comparison of a patient's medication errors to all other medications that the patient has been taking (The Joint Commission). This is supposed to be done at every transition in care where new medications are ordered, or existing ones are modified (The Joint Commission). However, in a recent study by The Joint Commission, many times the patient is unable to actively participate in the process, as they may be too ill, injured, young or disabled. In this case, a family member should be available to participate. This is one example of how policies and procedures can be developed to help reduce the occurrence of medicine errors.

Medication errors have a tremendous impact on the client, healthcare industry, and the economy. In the U.S. alone, medication errors injure 1.5 million people and cost billions of dollars to the healthcare system annually (Stencel, p. 1). The committee noted that estimates on medication errors might be low due to unwillingness to report medical errors for fear of litigation or loss of public trust among healthcare institutions (Stencel, p. 1). It is estimated that the costs of these errors result in an addition $3.5 billion dollars every year (Stencel, p. 1). These numbers reflect a major problem in the healthcare industry and one that is completely preventable.

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.