Medication errors – everyone in healthcare is aware; policies and procedures are in place; CPOE is in use – yet medication errors continue to occur.
A medication error refers to an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication.
An adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication
The statistics speak for themselves – Medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States. ADEs account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. ADEs affect nearly 5% of hospitalized patients, making them one of the most common types of inpatient errors; ambulatory patients may experience ADEs at even higher rates. Medication errors are also found during transitions in care.
Healthcare providers have access to more than 10,000 prescription medications. Approximately one-third of adults in the United States take five or more medications. According to the FDA, medication mishaps can occur anywhere in the distribution system:
- Prescribing
- Repackaging
- Dispensing
- Administering, or
- Monitoring
Common causes of such errors include:
- Poor communication
- Ambiguities in product names, directions for use, medical abbreviations or writing
- Poor procedures or techniques, or
- Patient misuse because of poor understanding of the directions for use of the product
In addition, job stress, lack of product knowledge or training, or similar labeling or packaging of a product may be the cause of, or contribute to, an actual or potential error.
Many organizations have published strategies, guidelines and tools to prevent adverse drug events. The Institute for Safe Medication Practices maintains a list of high-alert medications—medications that can cause significant patient harm if used in error. These include medications that have dangerous adverse effects, but also include look-alike, sound-alike medications. The Beers criteria, which define certain classes of medications as potentially inappropriate for geriatric patients, have traditionally been used to assess medication safety. Another tool to predict ADEs is STOPP criteria (Screening Tool of older Person’s inappropriate Prescriptions). AHRQ’s PSNET has published a table the presents strategies to prevent adverse drug events at each stage: prescribing, transcribing, dispensing and administration.
According to AHRQ’s PSNET, “Integration of information technology solutions (including computerized provider order entry and barcode medication administration) into “closed-loop” medication systems holds great promise for improving medication safety in hospitals, but the potential for error will remain unless these systems are carefully implemented and these larger issues (system flaws, human factors engineering issues, impaired safety culture) are addressed.”
Preventing ADEs is a priority for accrediting organizations and regulatory agencies. The Joint Commission has made improving medication safety a National Patient Safety Goal for all healthcare organization.
Medication errors are not specific to the United States. According to the World Health Organization (WHO), low- and middle-income countries are estimated to have similar rates of medication-related adverse events to high-income countries, the impact is about twice as much in terms of the number of years of healthy life lost. In March of this year, WHO launched a global initiative to reduce severe, avoidable medication-associated harm in all countries by 50% over the next 5 years. The Global Patient Safety Challenge on Medication Safety aims to address the weaknesses in health systems that lead to medication errors and the severe harm that results. It lays out ways to improve the way medicines are prescribed, distributed and consumed, and increase awareness among patients about the risks associated with the improper use of medication. The Challenge aims to make improvements in each stage of the medication use process including prescribing, dispensing, administering, monitoring and use.
Per WHO, “Most harm arises from systems failures in the way care is organized and coordinated, especially when multiple health providers are involved in a patient’s care. An organizational culture that routinely implements best practices and that avoids blame when mistakes are made is the best environment for safe care. The Challenge calls on countries to take early priority action to address these key factors: including medicines with a high risk of harm if used improperly; patients who take multiple medications for different diseases and conditions; and patients going through transitions of care, in order to reduce medication errors and harm to patients.”
References:
Agency for Healthcare Research and Quality, Patient Safety Network, Medication Errors, Last Update March 2015, https://psnet.ahrq.gov/primers/primer/23/medication-errors
U.S. Food & Drug Administration, Medication Error Reports, Late Updated October 2016, https://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm080629.htm
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