Medication errors are preventable events involving medicine that result in inappropriate or incorrect drug use and may cause harm or injury.
Medication errors include prescribing, administering, or filling a prescription for the wrong drug, wrong dose, or wrong route of administration to a patient. Medication errors can involve mistakes made by a physician or other prescriber, a nurse or other healthcare agent, a pharmacist, a family member or the patient themselves.
Medication errors may involve:
- Wrong medication
- Wrong amount
- Wrong time
- Wrong patient
- Wrong route of administration
They may also involve failing to note drug interactions, drug-disease state interactions, and drug-food interactions.
Preventing Medication Errors
The Institute of Medicine (IOM) published a report called “To Err is Human” which identified how medication errors make up a substantial source of preventable hospital errors. A follow-up to the report, released on its tenth anniversary showed how medication mistakes continue to harm innocent victims. In both reports, IOM recommended stronger oversight by the Food and Drug Administration (FDA) to address safety issues connected with drug packaging and labeling, and similar named drugs.
Other professional medicine and consumer advocate groups have also published a number of medication safety guides which recommend a variety of practices and tips to help prevent medication errors.
Why Medication Errors Occur
Many medication errors are caused by the confusion of medicines with similar names, such as primidone (a seizure medication) and prednisone (an anti-inflammatory medication), which is commonly confused with 12 other drugs. When a high number of name-related medication errors have occurred, in some cases manufacturers have changed the name of existing medications to prevent additional errors.
Medication errors can also occur due to improperly written dosage amounts involving decimal points such as mistaking a 25mg dose for a 2.5mg dose. Computer systems are now designed to help prevent these errors, but they can still occur.
The use of technologies such as Computerized Physician Order Entry (CPOE) systems to write prescriptions and Bar-Code Medication Administration (BCMA) can check that patients get the right medication, in the right amounts. It can also help to eliminate drug interactions, over prescribing and other problems with prescription and hospital administered medications. Both technologies are estimated to cut medication errors in half or more but are still not employed in every setting.
Packaging and Design May Add to Confusion
In a high-profile case in 2007, twin babies of actor Dennis Quaid and his wife were given 1,000 times the prescribed dose of the blood thinner heparin. According to Quaid’s testimony before Congress, the couple sued the drug manufacturer for the medication error, charging that the manufacturer was negligent in packaging different doses of the product in similar vials with similar blue labels.
This problem was not new. A year before, a similar medication error mix-up occurred when six infants in a newborn intensive care unit at an Indianapolis hospital were given excessive doses of heparin, leading to the death of three of them. After the Indianapolis deaths, the manufacturer issued a letter warning hospitals of the potential for medication errors, but the packaging was not changed for at least 12 months and it was discovered that the same packaging was still being used in the hospital treating the Quaid children.
When Medication Errors Have Caused Harm
Thought many technologies have been developed to reduce the number of medication errors in a variety of healthcare settings, they are not in place in all settings. In addition, human error at both the healthcare and patient level continues to occur. This means that unsuspecting patients will continue to be irreversibly harmed.
If you or a loved one has been harmed or suffered serious consequences due to a medication, you should have your case evaluated by a legal expert.