Medication Errors: Causes, Prevention, Liability, and the Apology
Van Dusen, Virgil, Pray, W Steven, Drug Topics
AN ONGOING CE PROGRAM OF THE UNIVERSITY OF FLORIDA COLLEGE OF PHARMACY AND DRUG TOPICS
Medication errors are a serious problem for pharmacists and society. Pharmacists fill the vast majority of I prescriptions or drug orders correctly, but even in the best-managed pharmacies errors still occur. Although medication errors are small in number, they may have a devastating effect on the patient and pharmacist. Fortunately policies can be implemented and technology used to reduce the error rate. This article explores the common causes of medication errors, error-prevention strategies, and possible liability, as well as how the pharmacist should respond to the patient after an error.
Medication error defined and identified
Medication errors are caused by a number of "wrongs," The wrong drug may have been prescribed or dispensed, the wrong strength dispensed, or wrong directions placed on the label. A provider may fail to give a medication or the patient may be noncompliant, failing to take a medication when prescribed. The definition of an error is any incorrect event occurring during the process of medication use.1
The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice; healthcare products, procedures, and systems, including prescribing; order communication; product labeling; packaging; nomenclature; compounding; dispensing; distribution; administration; education or monitoring; and use."2
Adverse drug event. In contrast an adverse drug event (ADE) is a medication-induced injury. Some ADEs are not medication errors (e.g., an allergic reaction in a patient with no history of allergy is an ADE). Other ADEs, however, are caused by errors.3 ADEs are common in hospitals, nursing homes, and outpatient/community settings.
Experts estimate that 1.5 million preventable ADEs occur yearly in the United States.4 A recent report from the Department of Health and Human Services indicates that among hospitalized Medicare beneficiaries, adverse events related to medication account for 31 % of total events.5 In these patients, events involving temporary harm were related to medication most commonly at 42%. Finally, medication-related preventable events were assessed at 50 %.5
Audit methods. Audits of completed pharmacy orders can identify medication errors. Researchers conduct random inspections of prescriptions in community pharmacies awaiting patient pickup. The actual contents of the vial are compared with the drug and strength listed on the label to discover whether an incorrect medication or an incorrect strength of the correct medication was wrongly dispensed. Researchers also compare the patient's name on the label to the identifying information on the outer bag to help detect wrong-patient errors.
Comparing information entered into the computer with the vial label using these methods is a powerful tool for determining the accuracy with which pharmacist and technician enter data and for reducing errors. When these investigative methods were employed in an outpatient medication-error prevention program at a Veteran's Administration outpatient pharmacy, the error rate decreased from 0,6% to 0,1% in just 12 months.6
History of errors
The Institute of Medicine (IOM) has lately focused much attention on medication errors, but medication errors have always plagued pharmacy. The 1848 Code of Ethics of the Philadelphia College of Pharmacy identified 4 specific reasons for errors (e.g., bad handwriting) often still significant today (Table I),7 To combat bad handwriting, a 2007 IOM study suggested that individual "states should enact legislation consistent with and complementary to the Medicare Modernization Act's electronic prescribing provisions and remove existing barriers to such prescribing,"4
Handwriting vs. …