Medicine Introduction Center

 

Medication Error: An abuse of patient



Kamal Shah1*, Nagendra Singh2, Jiteendra Ku. Gupta1 and Pradeep Mishra3

 

Lecturer, GLA Institute of Pharmaceutical Research, Mathura (UP), * 1

Research scholar, Dr. H. S. Gour University, Sagar (M. P. )2

Director, Pharmaceutical Research Institute of GLA, Mathura (UP) 3

 

 

A medication error is preventable, but that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the physician, patient or consumer. “One or medication errors, defined as an error in prescribing, or administering a drug if there are adverse consequences or not, are the leading cause of preventable injuries to patients. 2.3 These errors may, at any stage of drug administration from prescribing to occur for the patient.

 

A recent report by the Institute of Medicine (IOM) estimates that cause errors in medical management from 44,000 to 98,000 deaths annually in U.S. hospitals. In the U.S., it was suggested that the rate of serious medication errors is about 7%. 4

 

Examples 5-6

1) Hydrocodone is the narcotic ingredient that controls cough, shortness of breath of life may, if administered in an overdose or if the drug is administered more frequently as the cause. Should not be used in children younger than 6 years. On March 11, 2008, FDA reports indicate that patients health care for the younger age group than the approved 6 years and older, more often than the interval duration of administration of hydrocodone prescribed every 12 hours ( “prolonged release”) and that patients have the incorrect dose caused by misinterpretation of information given dose.

2) A physician ordered a 260-milligram preparation of Taxol for a patient, but the pharmacist prepared 260 milligrams of Taxotere instead. Both are chemotherapy drugs for various cancers and with different recommended doses used. The patient died a few days later, when death is not for the errors are linked because the patient was already seriously ill.

3) an elderly patient with rheumatoid arthritis died after receiving an overdose of methotrexate – a dose of 10 mg of the drug rather than the expected 10 mg weekly dose. Some dosing mix-ups have occurred because daily dosing of methotrexate is typically used to treat people with cancer, while low weekly doses of drugs for other diseases such as arthritis, asthma were prescribed, and chronic disease inflammatory bowel.

4) A patient, because 20 units of insulin as “U-20 has been shortened is dead”, but “U” for a “zero” incorrect. “As a result, a dose of 200 units of insulin was injected by mistake .

5) A man died after his wife mistakenly applied six transdermal patches to his skin at a time. Multiple patches of an overdose of fentanyl painkiller drug delivered through the skin.

 

6) A given patient developed a fatal hemorrhage when another limitation of patients to the anticoagulant warfarin.

There are several other causes of medication errors or poor communication, misinterpreted writing, drug name confusion, lack of knowledge of staff and lack of understanding of the patient in a direction of drugs. In most cases, medication errors are not attributed to a single person.

 

Types of medication errors

Medication errors can be roughly divided into prescription, dispensing or administering medicines error:

Prescription errors



errors of prescription drugs can be defined as a fake choice for a patient if the dose, strength, route, quantity, indication, contraindication. 7

Dosing errors

dispensing errors are occurring in every stage of the dispensation of the accounts for the receipt of a prescription at pharmacies for delivery of a product for the patient. These errors include the selection of the incorrect dosage / product. This happens especially if two or more drugs, a similar appearance or similar names (look-a-like/sound-a-like have errors). Other delivery errors are possible incorrect dose, incorrect medication, incorrect patient. 8

Medication errors

The “five rights” have long been the basis for nursing education in the drug he was giving the right dose of the right drug to the right patient at the right time from the right path. Includes Drug Administration substantive errors of omission errors, where administration abandoned due to a number of factors, e. g incorrect patient, lack of stock. Other types of medication errors in drug administration are incorrect technique, administration of expired drugs and improper preparation administered. 90-10

Additional factors that prescription errors are: 11

 

The lack of knowledge of prescribed medication, can help the recommended dose and the patient in case of prescription errors. Other factors include poor tax procedures with insufficient control, excessive workloads and poor financial management rules. Studies have also supported a relationship between errors and variations in the level of supply of light, time limitation and noise. It is suspected that distractions and interruptions lead to performance errors. Furthermore, the doses are not particularly challenging, dispensing unknown products, dispensing, a written order before it can lead to errors. 12

Methods to minimize Medication Errno13

Medication errors can be prevented as follows:

- Changes in the system of ordering, dispensing and administration of medicines.

- Use of Computerized Physician Order Entry systems.

- The right recognition of a drug before prescribing

- Print your name clearly on the prescription drug and patient

- Provides all the details ie name of the drug therapy of the drug, dosage, indications, duration of therapy

- Do not leave a “naked decimal. In nothing should always precede the expression of values e. g 0 Error Before dose is ten times due to the use of a final zero.

- Avoid using abbreviations and ‘eg ISMN, FeSO4, U.

- Knowledge of audio-a-like.

Bar code mark rule Suggest chose after a public meeting in July 2002 the FDA a new provision of barcodes on the marks of certain drugs and biological products. Health care workers are using bar code equipment, similar to supermarkets to ensure that the right drug in the right dosage and route of administration to the patient at the right time.

drug name confusion: To minimize the appearance of confusion between drug names that sound or if you check the FDA about 300 drug names a year before being marketed. The agency tests drug names with the ‘help of about 120 FDA health experts, which simulated on a voluntary basis, real situations of life to drugs.

The last time the FDA has changed its name after the drug was approved in 1994, when the thyroid medication Levoxine be confused with the heart medicine Lanoxin (digoxin), and some people were hospitalized as a result. Now the thyroid medicine is called Levoxyl, and the agency has received more reports of errors since the name change.

Drug labeling: The mark clearly lists active ingredients used, warnings, dosage, directions, other information such as how to store drugs and excipients. 14

Reductions in dispensing errors made by:

 

errors in drug administration may be reduced:

 

Completion

As health care is a prescription, question him to tell the name of the drug, the dosage is right and what he used the drug. Make sure that the instructions for all medications including the right dosage, storage requirements and to know any special instructions. In the hospital, question (or question a relative or friend) is given the name and purpose of each drug. Make sure your doctor the names of all medications without a prescription, saying food supplements and herbal preparations you are taking, whenever he or she will write a new prescription. This would avoid another kind of drug problem, unwanted and potentially serious drug interactions. Finally, do not be worried to question questions. If the name of medicine looks at the recipe is different than expected if the different directions, as thought, or whether the pills or drugs still seems different, your doctor or pharmacist. Question questions if you have some suspicion, a free and simple way to make sure you avoid becoming the victim of a bug drugs. Each physician shares the responsibility to identify factors for medication errors and use this knowledge to reduce their occurrence. Both experienced and inexperienced staff may be responsible for medication errors. A multidisciplinary approach to solving this problem should be encouraged to be with all stakeholders, address the issue of reducing medication error event. Development of a multidisciplinary approach has been slow, probably due to the reluctance or refusal to admit the doctor, pharmacist or nurse for a drug error.

 

References:

 

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Am J Health Syst Pharm 11-1995, 52:382-5

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14th www. FDA. gov/consumer/updates/medicationerrors031408. html