When prescribed medications are dispensed, patients believe what they receive is correct and safe for consumption. However, all too often medication errors occur, and the outcomes can be serious…even fatal. Considering up to 6,800 prescription medications and over the counter drugs are available in the United States, it is conceivable that errors are made when practitioners prescribe and pharamacies dispense drugs.
It is disturbing to know that yearly between 7000 to 9000 people die as a result of preventable medication error.
Add the hundreds of thousands of other patients who experience, but often do not report, an adverse reaction or other complication related to a medication, and this is a serious health issue. Each year in the U.S., preventable medication errors occur in 3.8 million inpatient admissions and 3.3 million outpatient visits according to the Network for Excellence in Health Innovation. Over 20 billion has been spent each year caring for inpatients and outpatients who have experienced medication-associated errors. Further consequences include psychological and physical pain, as well as a growing lack of trust within the healthcare industry by patients according to an article in The National Center for Biotechnology Information.
What constitutes a medication error? 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.”
Because there are various steps to getting a prescribed drug into the hands of a patient, there are opportunities for mistakes to be made along the way. The most common mistakes occur due to incorrect diagnosis, prescribing errors, dose miscalculations, poor drug distribution practices, drug and drug device related problems, incorrect drug administration, failed communication and lack of patient education, according to Michael R. Cohen, in Medication Errors, 2nd Edition, for the American Pharmaceutical Association in 2007.
Furthermore, the AMCP (Academy of Managed Care Pharmacy) states that preventable errors occur because systems for safely prescribing and ordering medication are not appropriately used. The AMCP has identified:
- A widely recognized cause of error is illegible handwritten prescriptions.
- Errors may result from insufficient or missing information about co-prescribed medications, past dose-response relationships, laboratory values and allergic sensitivities.
- Errors in prescribing can occur when an incorrect drug or dose is selected, or when a regimen is too complex.
- When prescriptions are transmitted orally, sound-alike names may cause error.
- Similarly, drugs with similar-looking names can be incorrectly dispensed when prescriptions are handwritten.
- Errors may occur because a prescription is never transmitted to a pharmacy, or a prescription is never filled by the patient.
- Physician sampling of medications can contribute to medication errors due to the lack of both adequate documentation and drug utilization review.
Case examples handled by Friedman and Martin include but are not limited to the following:
- An elderly person was prescribed a blood thinner but the pharmacy dispensed ten times the prescribed dose, resulting in the person almost bleeding to death, with an extended hospital stay.
- A person was given the wrong medication by a pharmacy that LOOKED like the correct tablet, but was not. She suffered headaches, nausea after taking the medicine for several days.
- A person was given the wrong medication when the pharmacy called out our client’s name- for example Sue Smith—but the prescription was for Sue Sanders. Our client, not realizing the name error, took the medication of Sue Sanders handed to her by the pharmacy, which was not even close to the medicine our client was supposed to get. Our client was ill for about three weeks, and in addition, didn’t get the NEEDED medicine this person was supposed to get.
- A person was given a medication by a pharmacy that belonged to another person when our client went through the drive in window to pick up the prescription, did not see that another person’s name was on the bag and the bottle, and took medication, resulting in nausea, headaches, diarrhea and generally not feeling well.
How can the 1.5 million preventable adverse drug effects caused by medication errors be reduced?
The answer is two-fold: on the practitioner side and the patient side to include people and systems.
For practitioners, the most effective dispensing practices ensure the correct medicine is delivered to the right patient, in the correct dosage and quantity, with clear instructions and in a package that maintains the potency of the medicine. They should be working in a safe, clean and organized environment where dispensing can be performed accurately and orderly. A prescribed discipline should be in place utilizing effective procedures. These include reading the labels accurately, counting and measuring carefully and guarding against contamination of medicines using sterile equipment and preventing skin from ever touching the medicine. Performance of dispensers should be regularly monitored for any irregularities. Finally, it is important to use care coordination strategies, interdisciplinary teamwork and information technologies that can significantly reduce preventable medication errors.
For patients do this:
- Make sure to look at your tablets/pills. Do they look like the ones you took before if it is an ongoing prescription? If you are not sure, look up an image of the tablet online.
- Look at the Rx name on the bag and the bottle. Make sure your name is there.
- Confirm the dosage you are supposed to take. If you are not sure, call your doctor.
- Look at the tablet/pill in the bottle and make sure it is the pill that is listed on the label.
Additional tips include:
- Talk to their doctor and pharmacist about all the medications you are taking and ask questions about why a medication is being prescribed and how and when it should be taken.
- Develop a system for keeping track of when they take their medications. A written medication log or a child-resistant weekly pill organizer may be helpful.
- Always store all medications up, away and out of sight of children or grandchildren.
In conclusion, it is widely accepted that medication error is the most common and preventable cause of patient injury. This includes the giving of the wrong drug or dose, by the wrong route of administration, to the wrong patient or at a wrong time. This is generally a result of substandard care, which could result in a medical negligence claim.