A Series of Unfortunate Mistakes: Medical Errors and How to Reduce Them Part I: Medication Errors

While heart disease and cancer are two leading causes of death most Americans are familiar with, what ranks third is much more shocking: medical errors.[1] Ranging from healthcare associated infection to poor communication, the mistakes made in hospitals and out-patient care result in 251,000 deaths a year: 9.5 percent of all deaths annually in the U.S.[2] With these errors come thousands of medical malpractice cases, and understanding the origins and solutions is important for identifying problems clients face, and the causes of those problems.

This is the first article in a series where different kinds of medical errors will be discussed, and solutions will be suggested to assist you and your clients when dealing with the repercussions of an imperfect system. The focus of this piece is a phenomenon occurring one million times each year, resulting in 7,000 deaths annually: medication errors.[3] Here is a basic overview:

 

Types of Medication Errors:

  • Adverse Reactions: Occuring when a patient is exposed to a medication that they react poorly to, adverse drug events account for nearly 700,000 emergency department visits and 100,000 hospitalizations annually. They are some of the most common types of inpatient errors.[4]
  • Overdoses: The most familiar medication error. The FDA discovered cases in which a 10-miligram weekly dose was confused with a 10-miligram daily dose, and where an abbreviated “U” for “units” was mistaken for a “0,” increasing 20 units of insulin to 200.[5]
  • Wrong Medication: Since many medications are clear liquids, medications can easily be confused, and the wrong one can be given to or taken by the patient.
  • Switched Prescriptions: Mistakes made by a hospital or pharmacy can result in patient medications being switched with other patients’ prescriptions. Patient can suffer from the lack of medicine they need or from the new, unnecessary medicine.

Causes:

  • Labeling: mislabeling, misinterpreted handwriting, switched labels[6]
  • Staffing: poor communication, lack of employee knowledge, fatigue, stress[7]
  • Additional: drug name confusion, lack of patient understanding about a drug’s directions, interruptions and distractions[8]

Drugs Prone to Errors:

  • Insulin: Errors include not accounting for the differences between insulin syringes and other parenteral syringes, storing multiple concentration and drug strengths next to each other, and design flaws of certain insulin pens.[9]
  • Sedatives: Given for procedures and during hospitalization, sedatives like chloral hydrate and benzodiazepines can lead to lethargy, hypotension, delirium, and increased risk of falling if used inappropriately.[10]
  • Opioids: Because some hospital patients can use patient-controlled analgesia pumps to control pain, these drugs carry a higher risk of injury or death.[11] The percentage of injuries associated with these pumps is three times higher than IV pumps due to erroneous pump programming or using the wrong medication.[12]

Vulnerable Populations:

  • Surgery Patients: Due to the time-sensitive nature of operations, medical professionals don’t double- and triple-check medications. One study found that an average of 10 medications are given during an operation, and an error occurs in about 1 in 20 medications, meaning an error is made every other operation.[13]
  • Geriatric Patients: Elderly patients take more medications and are more vulnerable to specific medication adverse effects.[14]
  • Pediatric patients: Children are at an elevated risk, particularly when hospitalized, due to the fact that many medications are dosed according to their weight.[15]

While medication errors are easily identifiable, the next post will focus on an often overlooked factor in preventing medical mistakes, but one that is essential to master: communication.

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