Preventing Errors in Medicine Medication Errors: Preventing Errors in Medicine

What is a Medication Error? A medical error is a preventable adverse effect of care whether or not it is evident or harmful to the patient. Medical errors are often described as human errors in healthcare.

Causes Poor communication Improper documentation Illegible handwriting Healthcare complexity Competency and training

Statistics The rate of death from medical errors in hospitals far exceed the rate of death from motor vehicle accidents and breast cancer combined. The annual death toll from hospitalizations is more than 424,000 people per year.

Statistics cont. 7,000 patients die each year due to sloppy handwriting. 42% of people have been directly affected by a medical mistake, procedure, or drug. The death rate for people aged 45-64 who took their prescriptions correctly, rose 90% in only five years. Preventable medication mistakes hurt 1.5 million patients yearly.

Cost of Medication Errors The annual cost of measurable medical errors that harm patients was $17.1 billion the in 2012.

Severity Levels of Medication Error Level 0 – Non-medication error occurred (potential errors would be classified here) Level 1 – An error occurred that did not result in patient harm Level 2 – An error occurred that resulted in the need for increased patient monitoring but no change in vital signs and no patient harm. Level 3 – An error occurred that resulted in the need for increased patient monitoring with a change in vital signs but no ultimate patient harm. Level 4 – An error occurred that resulted in the need for treatment with another drug or an increased stay. Level 5 – An error occurred that resulted in permanent patient harm. Level 6 – An error occurred that resulted in patient death.

Preventing Errors Always double check “high-alert drugs” by doing independent calculations. High-alert drugs are those medications that have an increased risk of causing harm to patients when used in error. Take time out between rechecking calculations: Healthcare professionals are more likely to find their own errors when there is time between rechecks.

A Pharmacists Role Pharmacists should participate in drug therapy monitoring and DUE activities to help achieve safe, effective, and rational use of drugs. Pharmacists should make themselves available to prescribers and nurses to offer information and advice about therapeutic drug regiments. Pharmacists should never assume or guess the intent of confusing medication orders. When preparing drugs, pharmacists should maintain orderliness and cleanliness in the work area and perform one procedure at a time with as few interruptions as possible.

CPOE Vision Statement “To develop, implement and maintain an efficient, reliable and responsive system of computerized provider order entry to enhance patient safety, provide decision support and meet regulatory requirements.”

The CPOE According to recent research, the best known way for hospitals to protect patients from errors is by adopting technology called computerized physician order entry, or CPOE. The physician enters orders for a patient on a computer that contains patient information such as key lab values, clinical condition, and allergies. The computer checks the safety and appropriateness of the order and sends it electronically to the pharmacy. The research suggests errors decline by as much as 85% when hospitals implement CPOE.

Conclusion Healthcare professionals should be diligent and focused throughout the process of medication dispensing. The rate of medication errors in the U.S. can be decreased with more emphasis on patient safety and overall competency.