MEDICATION ERRORS: PREVENTING & RESPONDING
“TOO ERR IS HUMAN”
• 1999 report by Institute of Medicine (IOM)
• Brought medical errors to the public’s attention
• Preventable errors were responsible for 7000 deaths per
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MEDICATION ERRORS: PREVENTING & RESPONDING
“TOO ERR IS HUMAN”
• 1999 report by Institute of Medicine (IOM)
• Brought medical errors to the public’s attention
• Preventable errors were responsible for 7000 deaths per year.
• 3% to 6.9% of hospitalized patients experience a medication error.
• Two follow up reports from the IOM found no significant change in rates of preventable errors.
• In a 2006 IOM study, it was estimated that some form of medication error resulted in harm to 1.5 million
patients
PREVENTING
• Most medication errors occur as a breakdown in the medication use system, as opposed to being the
fault of the individual.
• Key to preventing errors:
• Reporting of errors
• Reporting of potential errors
• Nonpunitive approach to error reporting or “Just Culture”
• QSEN initiatives
• Adverse drug events
• Many caused by Medication errors
• Adverse drug responses (ADRs)
• Allergic reaction (often predictable)
• Idiosyncratic reaction (usually unpredictable)
• Defined as any abnormal and unexpected response to a med, other than allergic
reaction that is peculiar to an individual patient
ADVERSE DRUG EVENTS: intersection of Med Error with Adverse Drug Events
MED ERRORS
• Preventable
• Common cause of adverse health care outcomes
• Drugs commonly involved in severe medication errors: central nervous system drugs, anticoagulants,
and chemotherapeutic drugs
• More potential for harm with “high-alert” medications
• SALAD (sound-alike, look-alike drugs)
• LASA (look-alike, sound-alike)
• Example: buspirone and bupropion & prednisone and prednisolone
ISSUES CONTRIBUTING TO ERRORS
• Errors can occur during any step of medication process
• Procuring
• Prescribing
• Transcribing
• Dispensing
• Administering
• Monitoring
• Organizational issues
• Educational system issues
• Sociologic factors
• Use of abbreviations
“NEAR MISS” VS “CLOSE CALL”
• Near Miss - Event or situation that did not produce patient injury, but only because of chance
• Close Call - An event or situation or error that took place but was identified and captured prior to
reaching the patient
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