MEDICATIOn ERRORS In VARIOuS SETTInGS 1 Medication Errors in Hospitals

Medication errors in hospitals are common and have the potential for causing serious harm. Most hospitalized patients are on intravenous (IV) medications where errors result in risk of serious injury and death. As stated earlier, To Err Is Human used hospital data and reported on patient safety problems that resulted in 44,000–98,000 preventable deaths a year. Medication errors played a major role in these deaths and in harm to patients that did not result in death. From the studies covered by this IOM report, 7% of all patients admitted to the hospital experience a clinically important medication error.1 _{In studies}

done in the 1990s, the average cost of these medication errors was $4,700 per admission.1

A limited number of medications dominate the list of drugs involved with major medi- cation errors in hospitals. These include insulin, heparin, warfarin, and narcotic analge- sics. Often, a lack of standardization contributes to harm because protocols differ among physicians. If physicians act alone in ordering medications, followed without question by a nurse’s transmission of the orders and a pharmacist’s filling the orders, physician errors are not recognized or questioned. Standardization of drug prescribing and administra- tion is a critical first step in reducing medication errors.10 _{Information technology and}

teamwork among the professionals can then interplay to create safe systems of medication administration.11

Hospital medication errors continue to capture headlines. For example, in two of the nation’s leading hospitals, newborn babies were given an adult dose of heparin due to a mix-up in heparin vials. In one of the hospitals, four babies died of bleeding complications. Tragically, one hospital did not learn from the other: These events happened a year apart. The following is the assessment of the Institute for Safe Medication Practices12_:

Recently, an error occurred at a hospital in which 10,000 units/mL heparin vials were used to flush the vascular access lines of infants rather than the 10 units/mL vials. Previously, a similar error had occurred at a different hospital when the 10,000 units/mL vials were stocked mistakenly in the space reserved for the 10 units/mL vials. After the occurrence of the first error, several recommendations were made in order to prevent a recurrence of this type of error such as separating the 10,000 unit/mL vials from all other strengths, verifying all drugs taken to be stocked in patient care areas, implementing bar-code, and using pre-filled heparin flush syringes instead of vials. Despite these recommendations, the second heparin error still occurred. This demonstrates two issues plaguing the healthcare industry that cause concern for patient safety.

The first issue is that most healthcare organizations are not doing enough to •

educate themselves about potential risks and errors existing both within the organization and externally. Many resources are available, including the ISMP newsletters, but because organizations rarely seek out this information and make recommended changes accordingly, the mistakes of others are often repeated.

136    ◾   Joseph E. Scherger and Grace M. kuo

The second issue is that healthcare organizations are not proactive enough when •

it comes to evaluating their own systems and procedures for the possibility of potential errors.

Errors in pediatric hospitals are at least as common as in adult hospitals and are often more serious due to the fragile nature of sick children, especially neonates.13–16 _Medication

administration in children often requires calculations based on weight and other variables; standardization and information technology that performs critical calculations allow for much greater safety.17

10.2.2 Medication Errors in Community Clinics and Medical Offices

Studies in community clinics and medical office practice indicate that outpatient medica- tion prescribing errors occur in between 7.8 and 21% of patients and adverse drug events occur in 18 and 25% of patients.2,18,19 _{Examples of the reported prescribing errors include}

inappropriate medication selection, omitting necessary information on the prescription, selecting incorrect dose or directions, unclear quantity to be dispensed, and potential adverse drug–drug interactions. Examples of adverse drug events include adverse reac- tions caused by a medication error or a previously documented causative drug. Medication discrepancies are prevalent among ambulatory care clinics, ranging from 26 to 76%.19

Examples of the medication discrepancies include medications that patients are taking that are not recorded in the chart or medications that are recorded in the chart that patients are not taking. Furthermore, medication errors from inadequate therapeutic monitoring commonly occur.19

Over three billion prescriptions were sold in U.S. outpatient and community pharma- cies in 2006; retail prescription-drug expenditures totaled $275 billion.20 _{As medication use}

increases, the risk of medication errors also increases. One cross-sectional study conducted in 50 community pharmacies located in six U.S. cities found the dispensing error rate to be approximately four errors per 250 prescriptions per pharmacy per day.21 _{Extrapolating}

from this finding, more than 50 million medication errors could occur from filling three billion prescriptions each year. Studies show that serious harm may come from these errors and that they are preventable.18,22

10.2.3 Medication Errors in Long-Term Care

Medication errors are common in long-term-care facilities, especially in nursing homes.23,24

Historically, the transmission of medication information from hospitals to nursing homes has been poor. Medication allergies and changes in medications are often missing in paper-based systems that require human transfers of information. The patient and family are often not available to consult about medications the patient takes, including the exact name, dose, or frequency of medications used by the patient. Medication reconciliation among facilities and providers is critical and is one of the most important strategies for new health information systems.7

Lapses in medication monitoring are thought to be the most common type of error in the nursing home setting, although only a limited number of studies evaluating errors

in this setting have been conducted. The frequency of errors associated with medication administration is estimated to range between 6 and 20 errors per 100 doses.2

10.2.4 Medication Errors in the Home

At home, medication errors occur when patients take the wrong drug or wrong dose or take the right drug and dose at the wrong time.25 _{In a study of 6,718 elderly home-}

care patients, 30% had potential medication errors when either the Beers criteria or the home health criteria were applied.26 _{The Beers criteria are widely used to “identify}

patterns of medication use that unnecessarily place older persons at risk of adverse drug reactions.”26 _{The home health criteria were developed to “identify home healthcare}

patients whose patterns of medication use and signs and symptoms provided sufficient evidence of risk of a clinically important adverse drug effect to warrant reassessment of the patient.”26

Errors also occur when patients do not take their medications. Medication noncom- pliance is estimated to cost $100 billion in the United States each year and is becoming a public health concern.27,28 _{The community pharmacist is in an ideal position to moni-}

tor medication use in the home and provide education to patients and families. A robust information system that helps pharmacists review patients’ medications and provides an interactive communication tool with patients’ physicians (e.g., http://MedActionPlan.com) can greatly facilitate this process.3,29