Errors, in medication

Meanwhile, these chemicals—like chemical agents encountered at work or in hobbies or as pollutants in air, water, soil, or food—can also cause harm. Sometimes the known mechanisms of action permit us to predict the nature of toxicity to be expected. A meta-analysis of prospective studies from U.S. hospitals indicates that 6.7% of in-patients have serious adverse drug reactions 0.3% have fatal reactions (Lazarou et al., 1998). In fact, estimates of 40,000 to 100,000 deaths per year attributed to errors in medical care, primarily due to adverse reactions to pharmaceuticals, make this phenomenon a major cause of death in the United States (Meyer, 2000). A tremendous... 

Bates, D.W., Preventing Medication Errors. In Medication Use A Systems Approach to Reducing Errors (D.D. Cousins, ed.). Joint Commission on Accreditation of Health Care Organizations, Oakbrook Terrace, IL, 1999, pp. 57-73. 

Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997 277 312-7. 

The latent errors in the medication use system have been described in several studies. Major contributors to errors in medication use were found to be knowledge gap related to drug therapy (30%) ... 

People with low health literacy may not understand the health risks associated with errors in medication management. Shame or embarrassment about their low literacy may deter them from seeking help with medication instructions. Pharmacists can assess health literacy using nonobtrusive screening tests such as the Test of Functional Health Literacy in Adults (TOFHLA), which is available in English and Spanish versions. This test includes items that assess the patient s ability to understand labeled prescription vials, blood glucose test results, clinic appointment slips, and financial information forms. 

Colorants, other than titanium dioxide, are rarely used in plastic containers however, the use of colorants is required for the cap. The American Academy of Ophthalmology (AAO) recommended to the FDA that a uniform color coding system be established for the caps and labels of all topical ocular medications. Industry new drug applicants are required to either follow this system or provide an adequate justification for any deviations from the system. The AAO color codes, as revised and approved by the AAO Board of Trustees in June 1996, are shown in Table 4. The FDA and AAO have extended the cap color scheme to differentiate different classes of newer Rx drugs for the benefit of the patient who may be using more than one product. The intent is to help prevent errors in medication and improve patient compliance. It is important for the pharmacist to explain this color coding to the patient and/or caregiver since it can be defeated if the cap is not returned to the proper container after each use. 

A. hi the extraordinary circumstance that a previously recommended international nonproprietary name gives rise to errors in medication, prescription, or distribution, or a demonstrable risk thereof, because of similarity with another name in pharmaceutical and/or prescription practices, and it appears that such errors or potential errors cannot readily be resolved through other interventions than a possible substitution of a previously recommended international nonproprietary name, or in the event that a previously recommended international nonproprietary name differs substantially from the nonproprietary name approved in a significant number of Member States, or in other such extraordinary circumstances that justify a substitution of a recommended international nonproprietary name, proposals to that effect may be filed by any interested person. Such proposals shall be submitted on the form provided therefore and shall ... 

Dhillon, B. S., Human Reliability and Error in Medical System, World Scientific Publishing, River Edge, New Jersey, 2003. 

Human Error in Medical Technology Use, Laboratory Testing, Radiotherapy, and Image Interpretation... 

With the increase in complexity and sophistication of medical technology, the occurrence of human errors in medical technology use has increased quite significantly [23,24]. One study reported that over 50% of medical device failures were due to operators, actions taken by involved patients, maintenance, and service [25]. Some important factors for the occurrence of human errors in medical technology are as follows [2] ... 

Discuss human error in medical technology use and laboratory testing. 

Misuse (incorrect use of equipment, nosocomial infections, errors in medication administration)... 

Jerome Groopman, How Doctors Think (Boston Houghton Mifflin Co., 2007). This highly readable and informative book deals specifically with cognitive errors in medical decision making. 

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