The Medication Error Reporting Project

When it comes to medication errors several things may occur such as adverse drug event, unexpected deterioration, and even death in severe cases. AHRQ (2015) states, “an adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication, and ADEs account for nearly 700,000 emergency department visits 100,000 hospitalizations each year.” There are many ways that errors may occur such as dispensary errors, prescription errors

Due to the large number of consumers being prescribed multiple medications, and the complexity of managing those medications, it is of a major safety concern that systems are in place for clinicians to reconcile patients medications to resolve any discrepancies in what the patient is using, or should be using, and newly added ones.

Medication errors are focused on: terms and definitions; incidence of and harm; risk factors; avoidance; disclosure, legalities & consequences (Wittich, Burkle & Lanier, 2014). Medication errors categories have been developed by the American Society of Health-System Pharmacists (ASHP). Examples of these categories are based on prescribing, omitting drugs not administered, timing, unauthorized drug, wrong dosage, wrong preparation, expired drug, not using laboratory data to monitor toxicity (Wittich, Burkle & Lanier, 2014). Additionally, this article examines in depth common causes leading to medication errors, drug nomenclature, similar sounding drugs, unapproved abbreviations and handwriting, medical staff shortages and manufacturer medication shortages. Even though this article provides an informative overview for physicians, other allied health personnel may benefit too. This is valuable knowledge for the health care professional not just physicians in order to provide safe care for their

In the Institute of Medicine (IOM) report in 2006, Preventing Medication Error, more than 1/3 of the 1.5 million adverse drug events that were recorded in the United States each year occurred in an outpatient setting. Likewise, in 2008 IOM released a report that laid emphases on the need for setting universal standards within prescribing and dispensing practices. Multiple studies reported that an increased prevalence of patient adherence to taking prescribed medications can be compromised by their inability to comprehend or understand the directions for taking the medication (Wolf et al., 2016). The inability to understand and interpret prescription drug labels were recognized as the leading cause of a large proportion of outpatient medication error and adverse events, as patients may possibly accidentally misuse a prescribed

Medication errors in the hospital setting have significant potential to result in serious injury and even death, thus effecting patients, families, health care professionals, and hospitals. Approximately 400,000 adverse drug effects (ADE) occur each year (Institute of Medicine, 2006). Considering that not all medication errors are discovered and reported, this number is likely to be underestimated. These errors not only contribute to patient morbidity and mortality, but also cause increased length of stay and hospital expenses. It is estimated by the Institute of Medicine (IOM) that $3.5 billion is spent annually as a result of ADEs (IOM, 2006).

Adverse drug events are the sixth leading cause of death in the United States and represent a significant financial burden to healthcare institutes at an estimated cost of $5.6 million per hospital per year (Meguerditchian N, Krotneva, Reidel, Huang, & Tamblyn, 2013). According to The Joint Commission (2006), medication reconciliation is the process of comparing a patient’s medication orders to all of the medications the patient has been taking. This reconciliation is done to identify and resolve medication discrepancies, which are unintended or unexplained

For many patients the scariest part of being in the hospital is having to rely on other people to control your life changing decisions. One large part of this is the medications one is given while in our care. I can only imagine what it must be like for patients to have a stranger to come in and start administering drugs to me. This would be especially scary if I did not know what these medications did, or what negative effects could be caused by taking them. Unfortunately, the fear of medication errors that many patients have are not unfounded. Estimates range from 1.5 to 66 million patients a year have medication errors occur while they are in the care of health care professionals. Considering all of the technology we have at our

In 1999, the Institute of Medicine (IOM) “Too Err is Human” estimated 98,000 deaths yearly due to medical error. Many of the errors are the result of adverse drug events, most of which occur during the prescribing and administration stages of medication administration (Guo, Iribarren, Kapsandoy, Perri, and Staggers, 2011). These errors are a significant cause of morbidity and mortality in hospitalized patients. One report estimates that when all types of errors are accounted for, every hospitalized patient can expect on average one type of medication error per day and during 2006, adverse drug events resulted in approximately 400,000 cases of error at a cost of over $3.5 billion (pp. 202-224). Studies have demonstrated a

Medication error is defined as the following by the National Coordinating Council for Medication Error Reporting and Prevention: “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling; packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use” (Anthony, Wiencek, Bauer, Daly, & Anthony, 2010). Medication errors cause increased length of patient hospitalization and morbidity and mortality (Pape

It is revealed that more mistakes are made in prescription and these mistakes associated with adverse drug reaction (ADR). To avoid prescription mistakes, in some health care settings pharmacist take that responsibility of correcting medication errors related with wrong drug, wrong dose, and prescription of allergic

It, therefore, implies that when a person gets the wrong name of the prescription drug, it means that the patient will not receive the required treatment. The other reason why we should have increased awareness on SALAD medications is that some of these drugs contain ephedra, caffeine, and phenylpropanolamine and people who have used the drugs containing these compounds have developed convulsions and fell into comas (Goldberg, 2013). In some extreme cases, the patient may develop complications which were not present before. Next, the customers should be able to minimize the risk of getting wrong medications. Also, the consumers can be aware of a particular drug that is administered and the proper use of the drug. The consumers can be able to confirm if the physician has clearly written the drug’s name by trying to read

Drug names, labels and packaging contribute to medication errors. Drug product characteristics as well as processes at the facility can contribute to medication errors. Organizations should systematically evaluate each high-risk medication. The names of several medications are strikingly similar looking or similar sound. The potential for errors caused by lookalike, sound-alike medications may be reduced by using type size that can read easily, prescribing where to write clearly, storage using TALL man lettering, increasing knowledge of patient education if changes in medications appearance, procurement of medicine, placing warning labels on stock bins, and storing high-risk medications in nonadjacent areas. Nurses, especially

Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error

Food and Drug Administration is warning health care professionals and patients that reports of confusion between Brintellix and Brillinta have resulted in the wrong medication being prescribed or dispensed (FDA, 2015). The main reason for confusion is the similarity in their brand names. As of June 2015, FDA has received 50 reports of medication error cases. The reports point out error in prescribing and dispensing, none of the reports indicated that the patient ingested wrong medicine (FDA, 2015). The report shows greater concern in the similarities in the way both of the medication sound, look and can cause greater confusion for prescribers and pharmacists. Even in one case, a pharmacist misinterpreted Brintellix as Brillinta, but luckily didn’t dispense the medicine as the patient had contraindication to blood thinners (FDA, 2015). FDA recommends both health care professionals and patients to report name confusion and medication errors that include Brintellix and Brillinta to the FDA MedWatch

It’s not inconceivable that a health care professional might see two alike-sounding medications confusing. After all, Alprazolam, and Lorazepam, or Hydrocodone, and Oxycodone, and Pentobarbital and Phenobarbital, look a lot alike when the names have been indecipherable and unintelligible by a physician and or medical professionals on a written prescription, and the less significance generic names instigated to ricochet and look monotonously parallel. In actuality, the perplexity isn’t even that out of the norm. Look alike and sound alike drugs names are regularly and continuously responsible for the drug mix ups and in some cases, traumas, and deaths.