Number: of medical errors

Since 1992, the Food and Drug Administration has received nearly 30,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher. There is no typical medication error, and health professionals, patients, and their families are all involved. Some examples ... 

To Err Is Human contains a four-part plan for decreasing the number of medical errors, and each part has implications for the pharmacy profession. To provide leadership and a research focus for patient safety. Part one recommends the creation of a center for patient safety within the Agency for Healthcare Research and Quality (AHRQ). Pharmacy organizations and pharmacists have the opportunity to contribute by including the study of medical errors in their applied research agendas. Using their expertise, pharmacists can provide input to the national goals, their content, and professional responsibilities for medicahon safety. ... 

Malahy B. The effect of instruction and labeling on the number of medication errors made by patients at home. American Journal of Hospital Pharmacy. June 1966 23(6) 283-292. PubMed PMID 5943307. 

Are all adverse events preventable The answer depends on the definition of "adverse event." Some patients will die in the natural course of events, irrespective of the quality of treatment provided. But this by itself does not mean that some number of medical errors are inevitable. 

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). 

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. 

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). ... 

Pharmacists have used avoidance of medication errors to justify expanding services. A pediatric critical care satellite was opened to reduce the rate of errors from a total of 17.4% in an intensive care nursery and 38% in a pediatric ICU. A large number of the errors (86.5%) occurred with medications possessing a high potential for serious adverse consequences. 

In recent years patient safety has become an important issue because of a staggering number of deafhs and injuries due to patient safety-related problems. For example, as per an Institute of Medicine report around 100,000 Americans die each year due to human errors in the health care system [1], Today there are many patient safety organizations in various parts of the world that advocate improvement in patient safety. A patient safety organization may be described as a group, association, or institution that improves medical care by reducing the occurrence of medical errors. 

This risk was dramatized and thrust into the public s awareness by the 1999 lOM report. To Err Is Human Building a Safer Health System/ which states that in any year, 44,000 to 98,000 Americans die because of medical errors. As Robert M. Wachter and Kaveh Shojania explain in their excellent book. Internal Bleeding The Truth Behind America s Terrifying Epidemic of Medical Mistakes, more people die each year in the United States as the result of medical errors than from AIDS and breast cancer combined. Others have pointed out that this terrible outcome is the equivalent number of lives that would be lost if a Boeing 767 full of passengers crashed every day of the year. 

Concentrated Oral Solutions. Presentation of a drug may be made in the form of a concentrated solution that allows the entire dose to be held within a volume of less than 5 mL (e.g., Intensol Concentrated Oral Solutions, Roxanne). This opens up another means of providing medication to the aged, infants, or any other patients experiencing difficulties swallowing. Such preparations can be mixed with food or drink. Taste and poor solubility are problems that may set limits on the number of successful formulations that can be prepared in this way. Also, small errors in the measurement of such preparations represent large errors in dosing. 

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. 

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