medication errors

Etiology

• medication delivery device
• misspellings
• clerical errors
• unintentional discontinuation of medications
• clinician fatigue, overcrowding, staff shortages, improper training, & incorrect information cited as risk factors for medication errors

Epidemiology

• 25% of insulin errors lead to patient harm
• insulin is involved in ~ 1/3 of fatal medication errors

Management

• measure & record weight in kilograms only
• standardized delivery devices should be dispensed for home use of liquid medications
• dosing for liquids should always be in milliliters.
• dosing instructions for home use of medications should be based on pictograms
• concentrations of high-risk medications, including drugs used for resuscitation, vasoactive agents, narcotics, & antibiotics should be standardized
• pharmacists should be incorporated as part of the emergency department care team

Notes

• medication errors will be reduced by electronic prescribing, but will present new challenges
• pharmacy led intervention can reduce medication errors in primary care
• medications errors common after hospital discharge
  • 50% discordance between hospital discharge medication lists & patients' self-reported medications
• World Health Organization (WHO) has launched campaign to reduce medication errors by 1/2 within the next 5 years
• estimated global cost = $42 billion annually

More general terms

• pharmacology

Additional terms

• medication reconciliation