Medication errors labels

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including prescribing order communication product labeling, packaging, and nomenclature compounding dispensing distribution administration education monitoring and use. 

Serious medication errors, including some leading to death, have resulted from the interpretation of the Cerebyx product labeling. The terminology on the label, which previously indicated the concentration as being 50 mg of phenytoin equivalents (PE) per milliliter, was misinterpreted as the total number of PEs per vial. Furthermore, health professionals were reportedly confused by the expression phenytoin equivalents, a prodrug concept introduced for this product. As a result, massive fosphenytoin overdoses were mistakenly administered. 

The FDA receives and reviews about 300 medication error reports each month and classifies them to determine the cause and type of error. Depending on the findings, the FDA can change the way it labels, names, or packages a drug product. In addition, once a problem is discovered, the FDA educates the public on an ongoing basis to prevent repeat errors. 

Berman A. Reducing medication errors through naming, labeling, and packaging. / Med Syst. 2004 28 9-29. 

The instructions on how and when to take medications, the duration of therapy, and the purpose of the medication must be explained to each patient by the physician and by the pharmacist. (Neither should assume that the other will do it.) Furthermore, the drug name, the purpose for which it is given, and the duration of therapy should be written on each label so that the drug may be identified easily in case of overdose. An instruction to "take as directed" may save the time it takes to write the orders out but often leads to noncompliance, patient confusion, and medication error. The directions for use must be clear and concise to avoid toxicity and to obtain the greatest benefits from therapy. 

Automation can reduce medication errors if it is implemented properly because it reduces the number of manual functions necessary to complete a task, thus reducing the chance for mistakes. Automation has helped to reduce the time that pharmacists spend preparing, labeling, and packaging medications, and this time can be reallocated to pharmaceutical care activities (Lewis, Albrant, and Hagel, 2002). 

Numerous reports of medication errors are being reported, some of which have resulted in patient injury or death. In a number of these reports, a medication was mistakenly administered either because the drug container (bag, ampule, prehlled syringe and bottle) was similar in appearance to the intended medication s container or because the packages had similar labeling. Obviously, the severity of such errors depends largely on the medication administered. 

For nearly 33 years, the USP has been reporting programs for health care professionals to share experiences and observations about the quality and safe use of medications. This year, the USP Center for the Advancement of Patient Safety publishes its sixth annual report to the nation on medication errors reported to MED MARX (Table 6). It was observed that drug product packaging/labeling is one of the main courses of medication errors in hospitals. 

A wholly owned subsidiary called Medical Error Recognition and Revision Strategies (Med-E.R.R.S. ) which works confidentially with pharmaceutical companies to predict error potential and thereby avoid problems that might stem from proposed drug names, labels, and packaging. 

Healthcare professionals can either complete a report form or contact the ISMP—Spain directly by e-mail, fax, or telephone to report medication errors with complete confidentiality. The types of medication errors submitted include confusion over look-alike or sound-alike drug names, ambiguity or similarity in packaging or labeling. 

A medication error happens when there is general agreement that a person should have done other than what they did and so the person is labeled as having committed a medication error. An ADE occurs when patient harm occurs as a result of a medication error (e.g., wrong me-... 

Recent examples of workshop topics at our two annual UKCPA symposia included sessions on compliance/ concordance, PlLs, off-label use of medicines, medication errors and ADR reporting. For the future, clinical governance and all its implications are high on the agenda and, to paraphrase the definition, we intend to help.... create an environment in which pharmaceutical care will flourish. 

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