A medication error is:
“Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional , patient or consumer .
an estimated 7000 deaths per year are caused by medication errors.
• More Americans die of medication errors annually than from workplace injuries.
• Medication harm have a cost, calculated at as much as $2 billion annually.
Second report,Crossing the quality chasm;A New Health System for the 21st centurey
Three problem categories introduced.
–failures to execute clinical care plans and procedures properly.
–use of health care resources and procedures in the absence of evidence.
failure to employ health practices of proven benefit.
TYPES OF ERRORS.
A. Wrong drug error.
B. Extra dose error.
C. Omission error.
D. Wrong dose/wrong strength error.
E. Wrong route error.
F. Wrong time error.
G. Wrong dosage form error.
Wrong drug error
A drug that was not ordered for a patient was administered.
for example, a patient accidentally received furosemide 40 mg orally.
Extra dose error.
A patient receives more doses of a drug than were ordered
a patient received a medication with breakfast for 5 days instead of 3 days
drug was not administered as ordered but was skipped.
patient was supposed to receive digoxin 0.25 mg orally but did not receive the dose.
Wrong dose or wrong strength error
wrong dose of a medicine or the wrong strength is administered
patient was supposed to receive warfarin .5 mg but received 5 mg instead.
Wrong route error
patient receives a dose of a medication by a route that was not ordered by the physician.
patient was supposed to receive
prochlorperazine 10 mg IM but was administered IV.
Wrong time error
patient does not receive a dose of medication at the time at which it was to be administered.
hospitalized patient with diabetes is scheduled to receive insulin immediately before breakfast but the dose is given 2 hr after breakfast .
Common Error Hazards
U, IU: unit (s)
The letter U can easily be misinterpreted as a number (e.g. , 0 or 4) .
results in serious harm with insulin and heparin
patient received 66 units of insulin instead of 6 units.
“6U” of regular insulin was misread as 66.
QD, Q.D,qd, q.d. (daily)
misinterpreted as “QID” or “qid” (four times daily
resulting in overdoses
When a dose is ordered and followed with a decimal point and a zero, such as 2.0 mg .
Decimal point may be missed and an overdose can occur .
warfarin 2.0 mg may be
misinterpreted as 20 mg
Lack of leading zero
drug's dose less than 1 mg.
dose is written without a leading zero.
digoxin .25 mg instead of digoxin 0.25 mg.
abbreviations for morphine sulfate and magnesium sulfate are quite similar and can be confused
confusing symbols, abbreviations
cc. instead of mL.
HCT for hydrocortisone
misinterpreted as a 0.
mistaken for mg.
misinterpreted as hydrochlorothiazide
Sound-a- like or look-a- like drug names
Amitriptyline and aminophylline
Cisplatin and carboplatin