Medication errors types

Medication Errors Types and Common Reasons for Their Occurrence... 

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. 

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. 

Thorough documentation of medication errors provides information about the severity of the error as it relates to the effeet on the patient, the product(s) involved, the competence of staff handling the produet or proeessing the order, any contributing factors that may predispose a product to misuse, and the suspected root cause of the error. USP adds certain codes to MER Program data in order to characterize the error as it was reported. These codes include the type of error and the possible eause(s) of error. The following list shows some of the produet eharaeteristics that have been recorded over 9 years to have caused or eontributed to a medication error. 

Compliance (sometimes called adherence) is the extent to which patients follow treatment instructions. There are four types of noncompliance leading to medication errors. 

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. 

For a number of reasons, including the difficulties inherent in proving a direct causal relationship between fatigue and adverse medical events and the lack of systems for reporting various types of adverse events and errors, few studies to date have examined the specific contribution of sleep deprivation to actual medical errors. Several recent studies, in attempting to unravel this relationship, have employed a number of different methodologies to assess prevalence, type, and risk factors for medical errors. For example, in one recent study of anesthetic... 

Define the types of medication errors that can occur during the ordering and dispensing process. 

What types of contributing factors lead to medication errors during the ordering process ... 

The sentinel event reports submitted to the JCAHO are reviewed and cataloged for error type and underlying causes. Medication errors are one of the most common types of sentinel events reported to the JCAHO. When a trend of similar errors is identified, the JCAHO issues a sentinel event alert, which alerts others of the risk and recommends actions to minimize risk in organizations. The first alert issued in 1998 focused on deaths due to the inadvertent IV push administrahon of IV potassium chloride (KCl). Awareness of these events and actions by pharmacists to remove concentrated KCl from patient unit floor stocks has markedly reduced reports of this type of error. Of the 27 subsequent alerts issued in January 2003, seven focus on different types of medication errors and prevention strategies. 

The therapeutic indications for BoNTs are numerous. They are used in the treatment of ophthahnological disorders (strabismus, Duane s syndrome, esotropia/exotropia), movement disorders (focal dystonias, blepharospasm), spasticity, neiuomuscular disorders, pain (headache, myo-facial pain), disorders of the pelvic floor (anal fissures), ear/ nose/throat disorders, cosmetic applications (wrinkles), and hyperhidrosis. The recent explosion in new indications for BoNTs in the treatment of a wide range of medical conditions also brings the possibihty for medical errors in BoNT dosing. Systemic botulism may result from injection of excessive doses of the potent neurotoxin. The most infamous case of systemic botulism involved the paralysis of four Florida patients, including the doctor, treated with BoNTs for wrinkles. The physician used non-FDA approved formulations of type A from Toxin Research International,... 

Typical presentation of medication error data in aggregate form by month (A) or categorized by error type oit a quarterly basis (B). 

To identify opportunities for reducing medication errorS/ it is important that each error be carefully reviewed by a limited number of individuals to gain intimate knowledge of each reported incident. Collection and classification of error data must be followed by use of a careful epidemiological approach to problem solving at the system level. Narrative data which may not be seen by looking at the categorical data alone/ can be used to provide important details about proximal causes and latent error that may have contributed to the event. Success in this type of error reduction requires the reviewers to read between the lineS/ look for common threads between reports/ and link multiple errors that are the result of system weaknesses. 

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. 

The two major types of performance measures are 1) rate-based performance measures, which measure an event for which a certain proportion of the events are expected to occur even with quality care (such as mistimed prescription refills) and 2) sentinel-event performance measures, which measure a serious event that requires an indepth review for each occurrence of the event (such as a medication error).To provide meaningful information, performance measures must be... 

Another important area of concern with prescription medications is the possibility of a medication error occurring. With the entire prescription process there is room for error of all types (Zellmer, 1993). Errors can... 

Medical error is an umbrella term given to all errors that occur within the healthcare system, including mishandled surgery, diagnostic errors, equipment failures and medication errors. As medicines are the most common interventions in the healthcare system, medication errors are probably one of the most common types of medical error. Research suggests that approximately 7000 patients a year are killed by medication errors in the USA (Kohn et ai, 1999), and in British hospitals the incidence and consequences appear to be similar (Cowley et ai, 2001 Dean et ai, 2002). 

Table 3.1 Studies that used spontaneous reporting as method of detecting medication errors of all types in paediatrics...

The review by Wong and colleagues concluded that the most common type of paediatric medication errors are dosing errors, especially tenfold errors (Wong et al., 2004). Other paediatric medication errors have been reported in the literature, including ... 

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