Adverse drug events medication errors

Keywords Medication errors Drug-related problems Adverse drug event ... 

Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL (2002) Medication errors observed in 36 health care facilities. Arch Intern Med 162 1897-1903 Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L (1995) Relationship between medication errors and adverse drug events. J Gen Intern Med 10 199-205 Cohen MR (ed) (2006) Medication errors. American Pharmaceutical Association, Washington, DC... 

Experience from hundreds of organisations has shown that poor communication of medical information at transition points is responsible for as many as 50% of all medication errors in the hospital and up to 20% of adverse drug events (IHI MedReconcilliation 2008). In our different settings at a university and county hospitals, we had errors in 40-85% of the elderly patients before starting a new practice. 

Detecting the incidence and type of adverse drug events (ADEs) and medication errors is important for improving the quality of health care delivery. Problems include missing dose, wrong dose, frequency, and route errors. The consequence (ADE) of the errors depends on medication and patient factors as described previously. Some of these problems are organisational and related to chart order system and prescribing. 

Medication errors are costly to both the patient (direct costs such as additional treatment and increased hospital stay) and to society (indirect costs such as decreased employment, costs of litigation) [1,5]. The cost of medication errors in a 700-bed teaching hospital based on a study in eleven medical and surgical units in two hospitals over a six-month period, was estimated to be 2.8 million dollars annually [2]. The increased length of stay associated with a medication error was estimated to be 4.6 days [2]. In a four-year study of the eosts of adverse drug events (ADEs) in a tertiary care center, 1% of these events were elassified as medication errors. The excess hospital costs for ADEs over the study period were almost 4,500,000 with almost 4,000 days of increased hospital stay [12]. 

Adverse drug events (ADEs), defined as any injury owing to a medication error, happen often. The Institute of Medicine has reported that at least 1.5 million preventable ADEs occur each year in hospitals and in people s homes. You can reduce your risk of having an ADE by having all your medications reviewed by your doctor or pharmacist. 

Poon EG, Cina JL, Churchill W, et al. 2006. Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy. Ann Intern Med 145 426. 

Medication errors occur primarily because of two reasons lack of knowledge or lapse in performance. In either case, if safety systems are not in place to prevent the error from going forward, an error can result. The more safety systems are in place, the greater the chance of the error being trapped before it gets to the patient. Leape and colleagues identified a number of proximal causes of medication errors in their study of causes of adverse drug events (Table 16.2). ... 

There is continued focus on adverse drug events and medication errors. Processes must respond to actual or potential adverse drug events and medication errors and properly report them internally and externally (e.g., to the FDA, ISMP, or USP). Other standards address how adverse drug events and medication errors should be addressed to improve systems, support staff education and training, and minimize the risk of medication-related errors and adverse events. 

FIGURE 26.1 Diagram showing the relationship between medication errors and adverse drug events. Because some adverse drug events are preventable, they are also considered to be medication errors (shaded area). (Adapted from Bates DW etal. ] Gen Intern Med 1995 10 199-205.)... 

American Society of Health-System Pharmacists. Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events, and adverse drug reactions. Am J Health-Syst Pharm 1998 55 165-6. 

American Society of Health-System Pharmacists. Suggested Definitions and Relationships Among Medication Misadventures, Medication Errors, Adverse Drug Events and Adverse Drug Reactions. Am. J. Health-Syst. Pharm. 1998, 55, 165-166. 

The traditional system of providing patient care— wherein physicians initiate drug therapy, pharmacists dispense medications, and nurses administer medica-tion.s—is often run in a disjointed fashion. This results in potentially avoidable adverse drug events that contribute to poor patient outcomes and increased medical costs. Efforts aimed at modifying the current processes of care to enhance efficiency of workflow, improve patient outcomes, and reduce medication errors arc needed. 

Adverse drug event and medication error management... 

The Institute for Safe Medication Practices—Spain (ISMP—Spain) is an independent, nonprofit Spanish organization committed to the prevention of medication-system errors and adverse drug events. 

It is the mission of ISMP—Spain to enhance the safety of the medication-use system and to improve the quality of patient healthcare. The most important goal is to reduce the risk of medication errors and preventable adverse drug events. 

To develop recommendations and effective strategies for preventing medication errors and reducing adverse drug events and to educate healthcare professionals and patients to ensure that these recommendations and practices are implemented appropriately. 

The edueation and dissemination of information is another primary objective of ISMP—Spain If everyone understands the nature and causes of medication errors, there is a much greater possibility of improving patient safety. In this sense, ISMP—Spain makes educational presentations and holds conferences at healthcare professional meetings to provide information about adverse drug events. ISMP—Spain also publishes opinion articles and practical articles in Spanish healthcare journals in an effort to broadly disseminate a culture of safety and error prevention. 

Medication Errors and Adverse Drug Events Prevention... 

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