Types of medication error and prevention
| Type of error . | Example . | Outcome . |
| Knowledge based | Being unaware of the interaction between ... | Warfarin toxicity |
| Rule based | Prescribing oral treatment in a patient ... | Lung aspiration or failure to treat |
| Action based | Being distracted, writing diazepam for d ... | Sedation |
What are the two most common medication errors?
This process is done to avoid medication errors such as:
- Missing medications (omissions)
- Duplicate medications
- Dosing errors
- Drug interactions
What are the categories of medication errors?
The researchers considered three types of medication error of increasing severity: where a mistake was caught and corrected before it was made; where the mistake was made but there was no potential harm to the patient; and where the patient might have been harmed but was not.
What are some examples of common medical errors?
What are the most common medical errors?
- Misdiagnosis. Error in diagnosis is a common medical error. ...
- Delayed Diagnosis. A delayed diagnosis can be as detrimental as a misdiagnosis. ...
- Medication Error. One of the most common mistakes that occurs in the course of medical treatment is an error in medication.
- Infection. ...
- Bad medical devices. ...
What are the common causes of medication errors?
The most common causes of medication errors are:
- Poor communication between your doctors
- Poor communication between you and your doctors
- Drug names that sound alike and medications that look alike
- Medical abbreviations
What are the 5 top medical errors?
The top five medical errors are misdiagnosis, delayed diagnosis, medication error, infection, and harmful medical devices. The top five medical errors are responsible for most instances of medical malpractice in health care.
What are the types of medical errors?
Medical errors typically include surgical, diagnostic, medication, devices and equipment, and systems failures, infections, falls, and healthcare technology. Missed diagnoses or injuries from medication are common in outpatient settings.
What is the most common medication error?
The three most common dispensing errors are: dispensing an incorrect medication, dosage strength or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications. Errors caused by drug administration can be made by the health care provider or by the patient themselves.
What is the most common type of medical error?
Misdiagnosis, failure to diagnose, and delayed diagnosis are some of the most common types of medical errors.
What is medical error in healthcare?
A medical error is defined as the "failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (1)." Most medical errors do not result in medical injury, although some do, and these are termed preventable adverse events.
What are the 4 levels of health care?
Primary care is the main doctor that treats your health, usually a general practitioner or internist. Secondary care refers to specialists. Tertiary care refers to highly specialized equipment and care. Quaternary care is an even more specialized extension of tertiary care.
What is an error in healthcare?
An error is defined as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning). 18. An adverse event is an injury caused by medical management rather than the underlying condition of the patient.
What are 5 different safety concerns in a healthcare setting?
Patient safety issues and concernsMedication/drug errors. ... Healthcare-associated infections. ... Surgical errors and postoperative complications. ... Diagnostic errors. ... Laboratory/blood testing errors. ... Fall injuries. ... Communication errors. ... Patient identification errors.
How many people are affected by medication errors?
reports annually associated with a suspected medication error. Furthermore, it was estimated that medication errors harm an estimated 1.5 million people annually. Every one of these people has a story to be told about an error that could have been avoided.
What medication error cost the life of a Canadian child?
According to a report from the ISMP Canada Safety Bulletin, the child had been receiving a prescribed dose of tryptophan at bedtime to treat a sleep disorder for about 18 months. A refill was ordered and filled. The child received the prescribed dose but was found dead in his bed the next day. The post-mortem toxicology test identified the antispasticity agent baclofen at the expected concentration of the prescribed tryptophan. It was determined that the child had received a dose of baclofen more than 20 times the maximum recommended pediatric dose. As ISMP notes, "This finding was consistent with a selection error having been made at the pharmacy, whereby one ingredient was inadvertently substituted for another."
What medication was accidentally dispensed instead of amlodipine?
An outpatient pharmacy accidentally dispensed the antipsychotic thiothixene ( Navane) instead of the prescribed anti-hypertensive medication amlodipine ( Norvasc ). The patient took the wrong medication for three months, leading to physical and psychological harm. "Despite the many opportunities for intervention, multiple healthcare providers overlooked her symptoms," the authors noted.
What medication did the nurse override safeguards?
The nurse supposedly chose to override safeguards when she could not find Versed in an automatic dispensing cabinet, typed "VE" into the cabinet's system, and then selected the first medication — vecuronium — that came up on the list. 2. Pegfilgtastim administered instead of filgrastim.
What medication did the nurse inject?
As the Associated Press and other news outlets reported, the nurse allegedly injected a 75-year-old patient with the paralytic anesthetic vecuronium instead of Versed, a sedative. The nurse supposedly chose to override safeguards when she could not find Versed in an automatic dispensing cabinet, typed "VE" into the cabinet's system, and then selected the first medication — vecuronium — that came up on the list.
What medication error took the life of an Air Force veteran and resulted in an $800,000 federal government settlement?
2. Pegfilgtastim administered instead of filgrastim. This medication error took the life of an Air Force veteran and resulted in an $800,000 federal government settlement, according to a report in The State. In early 2017, the patient reportedly went to Dorn VA Medical Center in South Carolina with nausea and vomiting.
Can medication errors lead to death?
But if the patient is less fortunate, a medication error can lead to significant harm, even death.
What are Medication Errors?
The National Coordinating Council for Medication Error and Prevention (NCCMERP) has approved the following as its working definition of medication error: “... any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the 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”.
What are the causes of errors in prescribing?
Errors in prescribing can occur when an incorrect drug or dose is selected, or when a regimen is too complex.
What are dispensing errors?
The term dispensing error refers to medication errors linked to the pharmacy or to whatever health care professional dispenses the medication. These include errors of commission (e.g. dispensing the wrong drug, wrong dose or an incorrect entry into the computer system) and those of omission (e.g. failure to counsel the patient, screen for interactions or ambiguous language on a label). Errors may be potential -- detected and corrected prior to the administration of the medication to the patient. 6 The three most common dispensing errors are: dispensing an incorrect medication, dosage strength or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications.
Why are preventable errors occurring?
Preventable errors occur because systems for safely prescribing and ordering medication are not appropriately used.
How does e-prescribing work?
E-prescribing Utilization of electronic prescribing by entering orders on a computer, better known as Computerized Physician Order Entry (CPOE), is a technology that could help prevent many medication errors. CPOE systems allow physicians to enter prescription orders into a computer or other device directly, thus eliminating or significantly reducing the need for handwritten orders. E-prescribing and CPOE can reduce medication errors by eliminating illegible and poorly handwritten prescriptions, ensuring proper terminology and abbreviations, and preventing ambiguous orders and omitted information. 13 More advanced CPOE software incorporates additional safety features that allow the physician to have access to accurate patient information, including patient demographic information such as age, medication history and medication allergies.
How many people are affected by medication errors?
Medication errors are among the most common medical errors, harming at least 1.5 million people every year. The extra medical costs of treating drug-related injuries occurring in hospitals alone are at least to $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs, the report says. 1 Medication error morbidity and mortality costs are estimated to run $77 billion dollars per year. 2 Patient safety is a major public health concern. The Academy of Managed Care Pharmacy (AMCP) recognizes the importance of this issue and supports programs that help achieve the goal of improved patient safety and prevention of medication errors. AMCP’s Framework for Quality Drug Therapy, 3 emphasizes and promotes public safety, continuous monitoring for accuracy in dispensing, reliability in the transmission of prescription and medication orders, and continuous review and upgrade of pharmacy operating systems.
How can electronic technology improve patient safety and reduce medication errors?
One way in which electronic technology can improve patient safety and reduce medication errors is through the use of standard machine-readable codes ("bar codes"). Medication bar coding is a tool that can help ensure that the right medication and the right dose are administered to the right patient.
How many hospitalizations are caused by medication errors?
But medication errors do happen. In fact, adverse drug events account for almost 700,000 ER visits and 100,000 hospitalizations every year. In many cases, these errors can lead to medical malpractice claims made against individual practitioners or even against whole care teams.
How early did the nurse give the meds to the patient?
The night before his surgery, a nurse saw that the patient was expected to receive meds at 6 a.m., but he was also slated to leave for the operating room before 6 a.m. To keep him from skipping a dose, she administered the medication two hours early, at 4 a.m.
What happened to the patient who was rushed to the ER with anaphylaxis?
They rushed her to trauma, where a nurse administered epinephrine to help alleviate her symptoms. Immediately, the patient felt severe, crushing pain flow through her body that caused her to pass out.
Why was the resident taking anticoagulant?
The resident was taking the drug, an anticoagulant, because they had a history of developing blood clots. During the nine-day window, the resident developed clots in their brain that eventually caused a large—and fatal—ischemic stroke.
Is medication error preventable?
The majority of medication errors are preventable, and knowing how they happen can teach you what to look out for.
Vanderbilt Nurse Charged with Reckless Homicide After Medication Error
The Tennessee Bureau of Investigation charged a former Vanderbilt registered nurse with reckless homicide and patient abuse after she allegedly dispensed a paralyzing drug to a patient instead of the standard anti-anxiety medication that the doctor had prescribed to the patient.
Veteran Dies After Medication Error at VA Hospital
After more than 20 years in the Army, a 40-year-old veteran had recently moved to Asheville, North Carolina. He thought he had the flu and went to the local VA hospital, just a mile from his new home, before the family’s moving truck had even arrived.
Hospital Gives Patient Paralyzing Agent Instead of Anti-Seizure Medication, Causes Death
The son of a patient reported to the local newspaper that he felt “pure anger” after learning that his mother had died because she was given rocuronium. This paralyzing agent caused her to go into cardiac arrest and suffer irreversible brain damage. She was supposed to receive fosphenytoin, an intravenous anti-seizure medication
How Can Patients Help Prevent Medication Error Injuries?
Being an active participant in your own healthcare is the best way to prevent medication error injuries. The first step in this process is to understand how these medication errors commonly happen. Some underlying reasons include:
When Should You Contact a Medication Error Attorney?
If you believe that you were harmed because of a medication error, you should contact a medication error attorney. Bertram Law Group, PLLC has served injured patients throughout Virginia, Maryland, and Washington, D.C.