Medication Errors:

Preventing Errors in Medicine

A medical error is a preventable adverse effect of care whether or not it is evident or harmful to the patient.

Medical errors are often described as human errors in healthcare.

What is a Medication Error?

Poor communication

Improper documentation

Illegible handwriting

Healthcare complexity

Competency and training

Causes

Statistics

• The rate of death from medical errors in hospitals far exceed the rate of death from motor vehicle accidents and breast cancer combined.

• The annual death toll from hospitalizations is more than 424,000 people per year.

7,000 patients die each year due to sloppy handwriting.

42% of people have been directly affected by a medical mistake, procedure, or drug.

The death rate for people aged 45-64 who took their prescriptions correctly, rose 90% in only five years.

Preventable medication mistakes hurt 1.5 million patients yearly.

Statistics cont.

The annual cost of measurable medical errors that harm patients was $17.1 billion the in 2012.

Cost of Medication Errors

Level 0 – Non-medication error occurred (potential errors

would be classified here) Level 1 – An error occurred that did not result in patient

harm Level 2 – An error occurred that resulted in the need for

increased patient monitoring but no change in vital signs and no patient harm.

Level 3 – An error occurred that resulted in the need for increased patient monitoring with a change in vital signs but no ultimate patient harm.

Level 4 – An error occurred that resulted in the need for treatment with another drug or an increased stay.

Level 5 – An error occurred that resulted in permanent patient harm.

Level 6 – An error occurred that resulted in patient death.

Severity Levels of Medication Error

Always double check “high-alert

drugs” by doing independent calculations.

High-alert drugs are those medications that have an increased risk of causing harm to patients when used in error.

Take time out between rechecking calculations: Healthcare professionals are more likely to find their own errors when there is time between rechecks.

Preventing Errors

Pharmacists should participate in drug therapy

monitoring and DUE activities to help achieve safe, effective, and rational use of drugs.

Pharmacists should make themselves available to prescribers and nurses to offer information and advice about therapeutic drug regiments.

Pharmacists should never assume or guess the intent of confusing medication orders.

When preparing drugs, pharmacists should maintain orderliness and cleanliness in the work area and perform one procedure at a time with as few interruptions as possible.

A Pharmacists Role

“To develop, implement and maintain an efficient, reliable and responsive system of computerized provider order entry to enhance patient safety, provide decision support and meet regulatory requirements.”

CPOE Vision Statement

According to recent research, the best known way for hospitals

to protect patients from errors is by adopting technology called computerized physician order entry, or CPOE.

The physician enters orders for a patient on a computer that contains patient information such as key lab values, clinical condition, and allergies.

The computer checks the safety and appropriateness of the order and sends it electronically to the pharmacy.

The research suggests errors decline by as much as 85% when hospitals implement CPOE.

The CPOE

Healthcare professionals should be diligent

and focused throughout the process of medication dispensing.

The rate of medication errors in the U.S. can be decreased with more emphasis on patient safety and overall competency.

Conclusion