How many medication errors occurred in 2017

Please enable Javascript in your browser and try again. Now Reading:. Membership My Account. Rewards for Good. Share with facebook. Share with twitter. Share with linkedin. Share using email. Istock Cardiovascular medications and pain relievers were responsible for two-thirds of the deaths included in a recent study. Prevention Tips Among adults, the most common types of medication errors identified in this study were related to dosing errors, taking the wrong medication and inadvertently taking a medication twice.

To avoid such errors, Hodges recommends that people: Talk to their doctor and pharmacist about all the medications they are taking and ask questions about why a medication is being prescribed and how and when it should be taken. Develop a system for keeping track of when they take their medications.

A written medication log or a child-resistant weekly pill organizer may be helpful. Always store all medications up, away and out of sight of children or grandchildren. Also of Interest Are your pills ready for a vacation? Leaving AARP. Got it! Please don't show me this again for 90 days. Cancel Continue. This medication error, occurring in December , has resulted in a reckless homicide charge against a Tennessee nurse, who recently pled not guilty to the charge.

As the Associated Press and other news outlets reported, the nurse allegedly injected a year-old patient with the paralytic anesthetic vecuronium instead of Versed, a sedative. The nurse supposedly chose to override safeguards when she could not find Versed in an automatic dispensing cabinet, typed "VE" into the cabinet's system, and then selected the first medication — vecuronium — that came up on the list.

He was administered doses of pegfilgtastim but should have received filgrastim. While both medications are administered by syringe and intended to stimulate white blood cell growth, the prescribed filgrastim can be taken daily. Following 11 days at the hospital and multiple doses of pegfilgtastim, the patient died after developing pulmonary toxicity leading to severe acute lung injury. This medication error at Vibra Hospital of Sacramento Calif. As The Sacramento Bee reports , referencing a CDPH regulator report , the patient's heart stopped following administration of Levophed, a blood pressure drug.

While the medication type was correct, a nurse administered 3,, times the prescribed dosage. Numerous factors contributed to this error, regulators determined, including the lack of safeguards for high-alert medications, administering nurse's lack of experience with Levophed, and failure for a second nurse to sign off on dispensing the medication. This medication error cost the life of a Canadian child. According to a report from the ISMP Canada Safety Bulletin, the child had been receiving a prescribed dose of tryptophan at bedtime to treat a sleep disorder for about 18 months.

A refill was ordered and filled. The child received the prescribed dose but was found dead in his bed the next day. The post-mortem toxicology test identified the antispasticity agent baclofen at the expected concentration of the prescribed tryptophan. It was determined that the child had received a dose of baclofen more than 20 times the maximum recommended pediatric dose.

As ISMP notes, "This finding was consistent with a selection error having been made at the pharmacy, whereby one ingredient was inadvertently substituted for another. The error and child's death has prompted his mother to push for mandatory reporting of all errors made by Ontario pharmacies.

Contributing factors to patient and caregiver error include low health literacy , poor provider—patient communication, absence of health literacy, and universal precautions in the outpatient clinic. Both low- and high-tech strategies have been designed to ensure safe medication administration and align with the nine rights of medication administration. Many low-tech strategies support all nine rights, including the use of standardized communication strategies and independent double check workflows.

Standardized communication : Health system communication standards are used to ensure right medication. Additionally, standard abbreviations and numerical conventions are recommended by The Joint Commission.

Of note, leading and trailing decimals i. Patient Education : To mitigate risk of error in the home, it is important for health care professionals to use clear communication strategies and routinely provide education to patients, especially when medication regimens are modified. Patient education is a core component of medication management, particularly with high-risk medications such as anticoagulation therapy.

Patients are educated routinely to ensure understanding of indication for therapy, intended outcomes, and signs and symptoms of adverse events. To help mitigate of wrong dose errors, warfarin tablet colors are standardized by their strength across all manufacturers. Patients are often advised to double check their tablet color upon getting a new prescription refill.

Optimizing Nursing Workflow to Minimize Error Potential : In health care settings, distractors during the medication administration process are common and associated with increased risk and severity of errors. Minimizing interruptions during medication administration and building in safety checks through standardized workflows are key strategies to facilitate safe administration.

There are many challenges associated with a true distraction-free zone; a study assessing feasibility of a "do not interrupt" bundle found that it was moderately effective but had limited acceptability and sustainability. Areas of increased high-risk medications administrations, such as the intensive care unit or emergency department, may have decreased compliance with non-interruption zones due to workflows and frequency of medication passes and titration events.

Health systems should identify the area where medication administration preparation by nurses occurs to ensure that minimal disruptions are present i. Additionally, strategies such as independent double checks are part of optimizing medication safety through nursing workflows.

The Institute for Safe Medication Practices ISMP also recommends judicious use of independent double checks involving two different nurses to intercept errors prior to administration with key high-alert medications.

Research by Campbell et al. Due to the additional time burden added to existing nursing workload, these double checks should be strategically targeted to the highest-risk medications and processes. Some medications are available in a specific format to ensure the correct route is utilized during administration.

For example, the epinephrine auto injector EpiPen for treatment of anaphylaxis is provided in a ready-to-use pen. This device, used for intramuscular injection in an emergency, does not connect to an intravenous IV line, thus preventing unintended administration via the IV route.

Another crucial educational tool for health systems is the use of medication pass audits or medication safety rounds. Focusing in on High-Risk Agents : Some classes of medications have a higher likelihood to result in patient harm when involved in an administration error.

The ISMP recommends a multipronged approach to mitigating risk with use of these agents. Strategies to mitigate potential for an administration error include protocolized prescribing, simplified instruction, robust documentation, and use of standardized administration practices such as dual nurse verification at the bedside. Health systems are encouraged to develop robust guidelines for use of these agents. Standardized labeling, clear storage requirements, and various clinical decision support strategies are used to ensure correct medication selection and administration technique.

The appearance of the medication itself may serve as a valuable safeguard. As an example, one type of eye drops prostaglandins has a turquoise cap on the bottle, across all manufacturers, while another completely different type of eye drop has a pink cap steroids. This distinguishing feature may be helpful for caregivers and patients alike, especially given that low-vision patients frequently use these drops. Similar techniques are employed with institutional labeling.

If a medication is supplied in a consistent manner with specific labeling, this may also reduce error. Pharmacy-prepared emergency kits frequently employ standardized labeling and instructions for this reason.

High-tech solutions commonly implemented within health systems include: barcode scanning of medication to ensure right medication, patients arm bands to confirm the right medication and the right patient, and s mart infusion pumps for IV administration to confirm the right administration rate a derivative of right dose and route with technology that inhibits over- and underdosing of titratable drips during pump programming.

Barcode medication administration: When used appropriately, barcode medication administration BCMA technology reduces errors in health system settings by using barcode labeling of patients, medications, and medical records to electronically link the right dose of the right medication to the right patient at the right time.

However, BCMA is subject to a number of usability issues and workarounds that can degrade its effectiveness in practice. Users may encounter blockades in the BCMA workflow, for example, when the patient's arm band is not readable, the medication is not labeled or not in the system, or the scanning equipment malfunctions.

A Dutch study using direct observation in four hospitals found that nurses used workarounds to solve BCMA workflow blockades in more than two-thirds of medication administrations, and workarounds were associated with a threefold higher risk of medication error.

Although smart pumps offer numerous safety advantages, they are also prone to implementation and human factors problems, such as difficult user interfaces and complex programming requirements that create opportunities for serious errors. Use of the drug library to ensure accurate pump programming is a key workflow step; not using the drug library as intended may negate the benefits of smart pump technology.

Given the complexity of manual pump programming, technologic advances allow for smart pump interoperability with the EHR, which allows the smart infusion pump screen to be pre-populated with information from the EHR. With an interconnected system of prepopulated smart pumps, additional resources may be needed to keep the system working its best.

Challenges include keeping DERS in the smart pump aligned with most current hospital practice, ensuring standardization across care areas and devices, and data collection and ongoing quality improvement. Some new technology supports the caregiver in assessing for the correct patient response to a medication. If retention of CO2 is detected, above a set threshold, this may indicate over sedation and respiratory depression. Based on this trigger, the pump can stop the PCA infusion, which may, in turn, reduce the possibility of further respiratory decline.

While this a helpful tool, manual assessment of patient response for medication therapy still remains of the upmost importance. Steps in the medication pathway are complex and interconnected. The healthcare industry utilizes a number of low-tech and high-tech strategies to mitigate risk of medication administration errors.