Prescription errors

Prescription errors are unintentional mistakes in the prescription, transcription, dispensing, and administration of medications. The patient either receives the medication incorrectly or fails to receive it altogether. Some prescription errors include wrong patient, incorrect medication, inappropriate dose, wrong time, wrong route of administration, and wrong rate of administration. For example, the profile of a patient shows that he is allergic to codeine, and yet he receives Tylenol 3 by an error. 

In writing on human error, Senders and Moray (1991, p. 128) conclude Human error rates can be reduced to as low a level as desired, at some unknown cost. The occurrence of a particular error at a particular instant, however, cannot absolutely be prevented. Even if the patient suffers no permanent harm, a service failure or mistake in a pharmacy is a significant event. The consequences of a service failure or mistake in a pharmacy include a deterioration of trust in the pharmacist and the system, the spread of negative word-of-mouth advertising, the possibility of legal action, possible board of pharmacy involvement, the erosion of customer patronage, and a diminished level of profit (see Chapters 7, 28, and 30 on minimizing the occurrence of prescription errors). 

Establish the context. What are the goals of the risk management process What are potential vulnerabilities of the business Do employees or patients risk injuries How might the reputation of the pharmacy suffer if a patient was injured owing to a prescription error or if his or her health condition was inadvertently made public by an employee Could costly claims be avoided by not providing certain services or products ... 

More patients using the hydrofluoroalkane (18%) withdrew from the study than patients using the chlorofluorocarbon (4.8%). Most of the withdrawals in both groups were unrelated to safety (9 and 3.2% respectively). The reasons for withdrawal included intercurrent illness, loss to followup, and inadvertent prescription errors. More patients using the hydrofluoroalkane withdrew because of an adverse event or because of the taste of the inhaler, 3.8 versus 0.9% and 3.1 versus 0.2% respectively. The authors concluded that the data supported the evidence already obtained in clinical trials that reformulation of salbutamol in a hydrofluoroalkane propellant does not result in changes in safety compared with a chlorofluorocarbon formulation. 

Buppert (2000) from the Gold Sheet makes the following suggestions for health care providers to reduce prescription errors and catch mistakes that might be hazardous to a client s health. 

Buppert, C. (20(K)). Avoiding prescription errors. Gold Sheet, 2(5), 1-4. 

Canada) from summer of 2000 emergency department Chart review of patients treated in emergency department Sample 1532 charts = no. of patients No. of medication orders = 1678 potential errors 10% of patients subjected to medication errors (10.1 % with prescription errors, 3.9% with drug administration errors)... 

Fontan et al., 2003 (France) 8 weeks Paediatric hospital Prospective study Prescription and administration documents were analysed daily and medical record analysis was used to compare the prescription with administration report Sample = 49 patients Prescriptions = 511 Prescribed drugs = 4532 Prescription error rate 20.7% (1.9 errors per patient per day) Administration error rate 23.5%... 

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