By Ron Conte, Pharm.D.
Each and every day, there are thousands of errors made with medication administration in the United States. In 2017, 1.3 million errors were reported. The majority of medication errors are preventable. Top drugs involved with errors include antihypertensive agents, opioids, and insulin. Medication errors may be made by the healthcare provider, including pharmacists, as well as by consumers (patients).
All healthcare professionals strive for an error-free practice. It is praiseworthy and suitable to work towards such a lofty goal. However, healthcare providers are only human. And to err is human, even in this age of high-tech medication systems. Consumers (patients) have as equally a difficult task being successful in consuming medications properly.
Before we proceed, it is proper to define what a medication error is. It is an unintended result (either of omission or commission) or an end-result that does not achieve the intended outcome. The most common types of medication mistakes include dosing errors, the wrong med administered, and inadvertent overdosing.
It is important to touch upon various categories in which medication errors can be commonly found:
- lack of knowledge of the drug by consumer (patient)
- lack of information for the consumer (patient)
- slips and memory lapses by the consumer (patient)
- transcription errors made by the healthcare provider
- faulty drug specific checks by healthcare provider
- errors with medication administration systems
- inadequate monitoring
- drug stocking and delivery problems
- drug preparation errors
- lack of standardization
There are many other categories leading to medication errors. But for now, let me briefly address some of the above categories.
Unless you are a healthcare professional, a consumer (patient) does not have the detailed knowledge to at times avoid medication errors. Sound alike, look alike medication names continue to create problems. Generic versus trade names can also be menacing. I often discovered some elderly patients taking both furosemide (generic Lasix) and Lasix as antihypertensive agents thinking these two pills are different. A few had blood pressure readings so low that they became incapacitated. Because furosemide (Lasix) is also a diuretic (eliminating fluid), some developed dehydration.
Consumers only receive the most salient points about specific drugs. It is important for all of us who take medication to have more input and control of our own drug therapy regimens. But it is not an easy task. Some drug therapy regimens can be quite complex. In addition, what are acceptable and safe parameters by which a consumer can govern her/his drug therapy?
Memory lapses occur even in those of us most knowledgeable about drugs. Some of us continue to miss taking drug doses even when we feel we have developed a fail-proof system for taking drugs properly. Another factor for memory lapses may be due to drugs that impair memory.
Faulty drug specific checks and inadequate monitoring of the drug may lead to major errors. If you are taking a thyroid medication, how often should thyroid function tests be ordered and reviewed? If you are prescribed a diuretic such as hctz, furosemide, spironolactone, or others, when should potassium levels be drawn? There can be major complications if specific lab tests are not ordered and reviewed at appropriate intervals.
Pharmacies may stock medications according to generic or trade names. It is possible that Zyrtec is stocked next to Zyprexa. During busy days, both technician and pharmacist must be very cautious and not pick the wrong medication. Zyrtec is a non-sedating antihistamine whereas Zyprexa is used to treat major behavioral health conditions. It seems obvious how disastrous a medication error can be with inappropriate dispensing of these two drugs.
As for drug preparation errors, there are a multitude of examples. Some drugs prepared for intravenous (IV) administration are only stable in normal saline. If prepared in another commonly used diluent, 5% dextrose, the drug may be unstable. So, it is imperative that there are standardized steps in how IV preparations are compounded. This would be imperative for all forms of drug preparation, especially chemotherapy.
Once again, this is a subject that requires a much more detailed review. Hospitals and other healthcare facilities are required to provide detailed medication error reporting both to the state and federal agencies that accredit them. The report is to include a process by which medication errors are to be reduced.
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If interested in learning more about medication errors, there are a number of online websites as well as a book entitled Medication Errors edited by Michael R. Cohen, MS, FASHP, and published by the American Pharmaceutical Association, Washington, D.C.