10 Medication Errors . . . and How You Can Prevent Them

10 Medication Errors . . .And How You Can Prevent Them

A 2006 report from the Institute of Medicine of the National Academics says preventable medication errors harm 1.5 million people every year, and cost at least $3.5 billion in extra medical costs to treat drug error-related injuries. According to the Institute of Medicine National Academy Press' To Err is Human: Building a Safer Health System (2000), medication errors account for approximately 1 out of 131 outpatient and 1 out of 854 inpatient deaths. When do these errors happen? According to a 1995 Journal of American Medical Association (JAMA) study, 39% of medication errors occur during prescribing; 12% occur during transcribing at the pharmacy; 11% occur during compounding at the pharmacy, and 39% occur during administration. While you as a consumer cannot prevent all these errors, you can seriously reduce the risk of suffering from a medication error by being an informed and involved patient (or family member). The 1995 JAMA study also said that only 2% of medication errors are intercepted at some point in the medication administration process. Clearly you may be your only safeguard from medication errors.

An article at caring.com lists 10 common, preventable medication errors. We're going to look at these errors in Cause Map form and then identify solutions that consumers themselves can implement to protect themselves from these medication errors.

First, a note on perspective: The solutions implemented to solve the issues illuminated in a Cause Map are different depending on whose perspective the Cause Map is made from. In these cases, our Cause Maps will be from the perspective of patients, not medical experts. There are many more solutions that could be implemented within hospitals or doctors’ offices, such as the use of electronic prescription filling, that we won't be discussing here. What we are looking for here is ways for patients to protect themselves against medical errors. (I use the term "patient" to refer to anyone taking medication, prescription or over-the-counter, and not necessarily hospitalized or under a doctor's care.)

Medication Error #1: confusing two medications with similar names

The Medication Error Reporting Project estimates that confusion surrounding drugs with similar names accounts for up to 25% of medication errors. A patient taking the wrong drug is an impact to the safety goal. In order for a patient to take the wrong medication, first he must be given the wrong medication from the pharmacy. This could occur with an unclear prescription, due to illegible writing or similar medication names that is not verified by the doctor, or by the pharmacist grabbing the wrong medication due to a similar name. Additionally, to receive the wrong medication the patient must not notice the error, due to confusion over similar sounding names, and/or if the patient does not know what the medication is for.

Patient solutions: Ask your doctor to write down the brand and generic names of the drug, as well as what it's for (diabetes, hypertension, etc.) on another piece of paper (other than your prescription). If you can't read her writing, ask her to write it down again, or write it down yourself and have your doctor check it. Once you've received the prescription, check it against what you have written down.

Medication Error #2: taking more than one drug that magnifies the side effects

Taking two drugs that result in a side effect, such as increased blood pressure, could result in that side effect being magnified. (With blood pressure, taking two drugs with a side effect of increased blood pressure could result in a dangerous rise in blood pressure.) This is also an impact to the patient safety goal. This can occur if a patient is prescribed more than one medication with the same side effect and the patient and pharmacist do not notice that the side effects are the same. A doctor might prescribe medications with the same side effects if the doctor is unaware of the similar side effects, or if the doctor is unaware of other prescriptions the patient is taking.

Patient solutions: Bring a list of all medications you're taking to your doctor's office and your pharmacist (known as a "brown-bag check-up"). Ask your doctor, and your pharmacist, about side effects. Read the patient notes enclosed with your prescription and if you have any questions or concerns, ask!

Medication Error #3: Overdosing by taking more than one medication with similar properties

Sadly, you've heard about this in the news. This kind of unintentional overdose with several different medications has killed several famous people. If a patient takes more than one medication with similar action (the risk is highest with drugs that act to suppress the central nervous system), even if the medications are for different purposes, there's a risk of overdose. Even some over-the-counter drugs can cause over-sedation (antihistamines, cold and cough medicine, and sleeping pills). The causes are very similar to what's above: the doctor, pharmacist and patient didn't notice the same action, possibly because they were unaware of all the medications the patient was taking.

Patient solutions: Make sure your doctor and pharmacist knows all the medications you're taking - prescription or over the counter. Read the warnings for each medication you take and be especially on the lookout for phrases that indicate a sedative effect (do not operate heavy machinery, for example) because this indicates the drug works by sedating the central nervous system.

Medication Error #4: Getting the wrong dosage

Taking the wrong amount of medication can be caused by getting the wrong dosage, or the wrong frequency. Generally this happens when the dosage or frequency instructions from the pharmacy are incorrect, due to illegible writing or confusing abbreviations (see theList of Error-Prone Abbreviations) on the prescription itself, and the patient doesn't notice the error, either because he doesn't know what the amount should be, or because he doesn't check it at the pharmacy. Additionally, it has been noted that using a non-standard measuring device, such as a kitchen spoon, can result in the wrong amount of medication being administered.

Patient solutions: Remember that sheet where you had the doctor write down all sorts of information about your prescription? Make sure you have her add the dosage and frequency as well. And, as always, if you can't read it, chances are the pharmacist won't be able to either. So, ask your doctor to write it again (or type it). Double-check your prescription at the pharmacy and when dispensing medication (prescription or over-the-counter) use the syringe or cup that came with it. That will ensure better accuracy for the dosage.

Medication Error #5: Drinking alcohol while taking medication

Lots of medications, both prescription and over-the-counter, should not be taken at the same time as alcohol. It can result in dangerous side effects, or alcohol poisoning, if the medication already has alcohol in it. Drinking alcohol with antibiotics can cause amplified side effects, severe reactions, or can even decrease the effectiveness of the antibiotics. Keep in mind that some cold medicines contain alcohol, which could result in the same effects.

Patient solutions: Ask your doctor and pharmacist about alcohol interacting with medication. If you think you won't be able to stop drinking alcohol while on the medication, ask about alternatives. Read the labels on any other-the-counter medications you're taking to check if alcohol is listed as a risk factor, or if alcohol is present in the ingredients. Make sure you also check the labels of any other-the-counter medications you're taking to see if alcohol is an ingredient. (Learn more from the Mayo Clinic.)

Medication Error #6: Taking the same generic and name-brand drug at the same time

Yep, it can happen, especially now that more and more insurance plans are requiring generics be used whenever possible. If a patient doesn't know the generic equivalent of the name-brand, or if the patient's pharmacist doesn't know what medications are being taken, this can be a concern.

Patient solutions: These are repeats of previous solutions, but we'll repeat them here for emphasis. Get your doctor to write down the name brand and the generic. Make sure your pharmacist knows all the medications that you’re taking.

Medication Error #7: Taking over-the-counter drugs that interact with your prescriptions
Medication Error #8: Eating and drinking food that interacts with your prescriptions

So you've done all the things we asked, and none of your drugs interact. You go home feeling very pleased with yourself, but then you get an upset stomach and grab the Maalox. Or, you throw back some grapefruit juice. This could result in serious reactions with your prescriptions.

Patient solutions: Whenever you get a new prescription, ask your doctor if there are any possible interactions with over-the-counter (OTC) medications that you should look out for, especially OTC medications you frequently use, or if you're a big grapefruit juice drinker (which inhibits an enzyme used to metabolize many drugs). If you're not sure, give your doctor a call. (Learn more from the Mayo Clinic.)

Medication Error #9: Not taking a dose appropriate for your kidney or liver function

Your liver and kidneys clean out foreign substances in your body, including medication. If your liver and/or kidneys lose some of their ability to function, you may end up with too-high levels of medication in your bloodstream. This is something your doctor should be looking out for, but studies say some aren't.

Patient solutions: Read that packet of annoyingly small print information that came with your medicine. If it mentions liver and/or kidney function, make sure you ask your doctor if you should be screened.

Medication Error #10: Taking medicine unsafe for your age

According to United States Pharmacopeia, 55% of medication errors involve seniors, and 9.6% of these errors caused harm. As we age, our bodies process medications differently. So, just as there are medications unsafe for young children, there are medications that should not be used in persons over the age of 65. Luckily, there's a list, known as the "Beers list" after the researcher who compiled it.

Patient solutions: Read the Beers list, print it out, and show it to your doctor. Check the prescriptions you already have at home against the list.

Learn More

FDA 101: Medication Errors
Think Reliability :: Root Cause Analysis
Cause Mapping I - Effective Root Cause Analysis Workshop TrainingCause Mapping II Root Cause Analysis Facilitation and Documentation Workshop Training
Sitemap     Copyright © ThinkReliability 2011
Root Cause Problem Analysis