Medication Errors

Medication errors are much more prevalent in U.S. hospitals than Americans think. In December, 2002, Medmarx, the anonymous national reporting database operated by U.S. Pharmacopeia (USP), issued a report finding that administering drugs using incorrect techniques continues to be a serious cause of injury to hospital patients, increasing costs to insurers. This third annual report is one of the most comprehensive accumulations of data available. It reports on 105,603 medication errors which were voluntarily reported by 368 facilities nationwide.

Medication errors are not just limited to overdosing patients on their prescribed medications. Such errors also occur in the administration of the wrong medications, the failure to timely give the appropriate dose of the ordered medicines, the improper calculation of the correctly ordered dose of medicine, or the failure to order the proper medicines under the circumstances. Many medication errors fortunately do not result in any long term harm to the patient. Others can lead to immediate injury and death.

According to Medmarx, 2.4% of the total errors resulted in patient injury. Of this number, 353 errors required initial or prolonged hospitalization and 70 required life-sustaining intervention. 14 resulted in death. Virtually all of these types of medication errors are avoidable. However, in today’s healthcare environment, hospital CEO’s have more incentive to be worried about the bottom line than they do about spending money on safety. They would rather buy a piece of expensive equipment which will attract new patients and new revenues than spend their tight budgets on computer hardware and software currently available to help prevent these errors.

Medmarx’s 2001 data report indicates that healthcare facilities attribute medication errors to many causes such as distraction (47%), workload increases (24%), and staffing (36%). More than 58 % of errors in the emergency department could be attributed to an improper dose, an omission, or a prescribing error. Heparin, a blood thinner used to treat and prevent blood clots, received the most reports of improper dosage.

In addition to the incidents noted in the Medmarx report, many other errors occur due to the lack of communication and follow up between the ordering physician, the hospital pharmacy and the hospital personnel, like nurses, actually administering the medications.

A recent incident at one of the local hospitals is illustrative of how this breakdown can occur. The physician ordered a 1mg dose of a particular medicine. That handwritten order was initially properly transcribed in a handwritten form by the pharmacy. However, when the medicine was filled, the typewritten order was inadvertently changed to reflect the dosage of the vial the medicine came in (5mg). The nurse administering the medication did not check the physician’s order against the pharmacy order and thus improperly administered 5 times more medication on two occasions than the physician ordered.