Long-Term Care Crying for More Med-Error Reports

By Cardinale, Val | Drug Topics, November 20, 2000 | Go to article overview

Long-Term Care Crying for More Med-Error Reports


Cardinale, Val, Drug Topics


At an assisted-living facility, a home care agency nurse enters a room shared by two female residents. The nurse points to a patient, states her name, and asks if she's the one to receive the insulin treatment. The patient says Yes and, after her blood sugar level is tested, receives 15 units of insulin from the nurse. Not long afterwards, the patient goes into crisis. As it turns out, she's not diabetic. The insulin was given to the wrong patient.

A rare occurrence among the elderly? Not so, said Rosaly Correa-de-Araujo, M.D., Ph.D., who related that incident at the American Society of Consultant Pharmacists' annual meeting earlier this month in Boston. Recently, she joined ASCP as program director of geriatrics and international. She had served as liaison with U.S. Pharmacopeia's geriatrics advisory panel. For USP, she conducted a study of medication errors among the elderly based on a review of USPs Medication Errors Reporting (MER) database between 1995 and 1999.

The review identified 609 reports of med errors in the elderly among a total of 3,815 reports studied. Of those 609 reports, 24% caused harm or led to a fatal outcome, Correa-deAraujo told ASCP members. By comparison, 15% of all reported errors caused harm or a fatality.

Correa-de-Araujo traced 49% of the geriatric med errors to dispensing errors, 24% to administration errors, 21 % to prescribing errors, and 0.5% to monitoring errors. The most frequent types of errors, she said, involved the dispensing of unauthorized drugs, improper dosages, and errors of omission. Among products most frequently linked to med errors in the elderly were insulin, morphine sulfate, warfarin/heparin, and potassium chloride.

From a systems perspective, there are five major causes of med errors in the elderly, according to Correa-de-Araujo. They are:

* Practitioners who lack the knowledge; fail to follow protocol or procedure; provide inaccurate, confusing, or incomplete orders; fail to monitor properly, or at all; and do not counsel the patient. She cited instances in which a practitioner crushed a long-acting verapamil to improve patient compliance, forgot to check the nursing home record before prescribing a contraindicated drug, and administered an antibacterial combination product to a patient on Coumadin for several years.

* Communication breakdowns, such as transcription errors and illegible orders. "I found numerous reports indicating that verbal orders were incorrectly heard," she said.

* Inadequate safeguards and failures in the distribution system itself. …

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