Medical error

Discuss the importance in participating in the MedWatch programs and the Medication Errors Reporting Program. 

USP MEDICATION ERRORS REPORTING PROGRAM Presented in cooperation with the Institute for Safe Medication Practices The USP Practitioners Reporting Network is an FDA medWatch partner... 

Appendix C contains a United States Pharmacopeia (USP) medication errors reporting program form, which is used by health care professionals for sharing information of medication errors to prevent them from occuring again. Also included is text explaining medication error and the USP... 

H. influenzae type b and influenza vaccines have the potential for confusion and medication errors because of the similarity of the names. Care should be taken when ordering, dispensing, and administering these vaccines. 

Outline actions for all health care providers to prevent medication errors with cancer treatments. 

Cohen MR, Anderson RW, Attilio RM, et al. Preventing medication errors in cancer chemotherapy. Am J Health Syst Pharm 1996 53 737-746. 

Policy makers, practitioners, and scholars from a variety of disciplines have recently embraced a new approach to risk reduction in health care—a "systems approach"—without proposing any specific reforms of medical liability law. The Institute of Medicine (IOM) placed its imprimatur on this approach in its recent reports (Kohn et al., 2000 IOM, 2001). In its simplest form, a systems approach to risk reduction in health care posits that an injury to a patient is often the manifestation of a latent error in the system of providing care. In other words, a medical mishap is the proverbial "accident waiting to happen" because the injury-preventing tools currently deployed, including medical liability law, are aimed at finding the individuals at fault rather than the systemic causes of error. Coexistence of a systems approach to error reduction and medical liability law as a conceptual framework for policy makers implies that the latter is likely to evolve in an incremental fashion as the former makes more visible different aspects of the medical error problem. 

The prototypical form of error in the health care system that could be reduced by a systems approach is medication error. The kind of error identified in the literature—overdose of chemotherapy, injection of the wrong drug, etc.—sometimes leads to either injury or death, the kinds of harm that are the central concern of after-the-fact medical liability adjudication. Phar-macogenomics introduces not only another conception of harm—genetic risks—but also new ways of developing and prescribing drugs. 

Drug-related problems and medication errors Wrong drug or dose... 

The number of medications increases the risk of ADR (Gurwitz et al. 2005). Medication errors at all levels also increase risk of ADR. These errors are e.g. wrong dosage or wrong medication (commission error). It has further been shown that transfer of elderly patients between different care levels increases the risk of ADR (Cooper 1999). 

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

Box 7.1 Starting point for reducing medication errors in hospitals... 

Follow-up on medication errors, including knowledge of routines, incidence reporting, root case analysis etc. 

It should be stated that medication errors can be made by health care professionals, but also by the patient, or a combination of both as highlighted in Table 7.1. Different aspects of these errors, consequences and interventions for improvement are presented in this book... 

Table 7.1 Reasons for medication errors based on responsibilities Health care professional Shared Patient/spouse/ relative...

Since the elderly use many drugs they are at high risk for medication errors and also for medication injuries, causing waste of resources and human suffering... 

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... 

Flynn EA and Barker KN (2006) Medication errors research. In Cohen MR (ed) Medication errors. 

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. 

Each time a patient moves from one setting to another, clinicians should compare previous medication orders with new orders and plans for care and reconcile any differences. If this process does not occur in a standardised manner designed to ensure complete reconciliation, medication errors may lead to adverse events and harm (IHI MedReconcilliation 2008). Several national organisations round the world have now produced help to reduce errors with medication reconciliation. Some examples are given below. 

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. 

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