Medication & Medical Errors

Medical error

A medication (medicinal product) is the one that is intended to be taken by the patient for prevention, treatment or diagnosis of the disease. Medication is the process (act) of giving medicines to a patient for any of these purposes.

Medication include chemical compounds i.e. drugs, prodrugs (inactive form of active drugs), biological products, diagnostic agents (contrast media),vaccines, blood products (packed RBCs and Platelets), gene therapy, and stem cells.

Medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while medication is in the control of the healthcare professional, patient, or consumer. Such event may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use”.

Medication error is essentially a failure in the treatment process that leads to, or has potential to lead to, harm to the patient. The magnitude of medication errors can vary from 5% to as high as 77% depending on type of patient care (outpatient clinic vs hospitalized), age of the patient (elderly above 75 years are more vulnerable), prescribing multiple drugs, poor communication, cultural issues and country specific systems. It has been estimated that in some countries approximately 6-7% of hospital admissions appear to be medication related, with over two-third of these considered avoidable and thus, potentially due to errors.  

Treatment process involves all medications as stated above. Medication errors can occur as follows:

  1. Wrong prescription: irrational drugs or combinations, prescribing ineffective medicines, underprescribing, overprescribing, inappropriate dosage selection.  
  2. Prescription writing: illegibility
  3. Dispensing error by the pharmacist
  4. Repeat prescribing without full check up
  5. Manufacturing issues: inappropriate dosage strengths, wrong formulation, contamination or adulteration, misleading packaging.   
  6. Patient errors: wrong dose, wrong route of administration, wrong frequency, wrong duration of use.
  7. Monitoring errors: failure in alteration of therapy at required time, alteration of therapy at wrong time. 

These medication errors could be due to lack of knowledge, omission of set rules, action based slips, technical reasons or memory based errors.

Knowledge based errors could be due to oversight by the physician or being unaware of the potential harm due to drug interactions or other adverse effects. The common errors could be lack of information on drug allergies before prescription, or several drug-drug interactions leading to serious and fatal adverse effects.

Omission of set rules could be due to casual approach or not reviewing the full literature on the product. The common error could be injection at wrong site (lateral thigh in place of buttock), subcutaneous injection administered by intra-muscular route, inadvertent IV injection etc. Another case could be prescribing oral treatment to a patient with swallowing difficulty or in cases of excessive vomiting. The off-label and unlicensed use of medication is widespread, which may increase the risk of avoidable medication associated harm.   

Action based (slips) is often found at dispensing site. Dispensing of diazepam (sedative) in place of diltiazem (cardiac medicine). These are mostly due to inattention that occurs during routine prescribing, dispensing or drug administration. Medication used in children present additional challenge of proper dosing. Paediatric prescribing require weight adjusted dosage regimen and other calculation that is not commonly encountered in adults. Physicians may not accurate doses based on weight and may cause potential harm to the patient. Further, children often receive liquid medication that may cause dosing errors as high as 40%.      

Technical reasons for medication errors is mostly due to illegibly written prescription.

Memory based errors (lapses) as forgetting to specify daily maximum dose and duration of treatment.

Factors leading to medication errors:

  1. Healthcare Professionals:
  2. Casual attitude
  3. Lack of training
  4. Inadequate subject knowledge and experience.
  5. Inadequate knowledge of patient
  6. Underestimating the risk
  7. Overworked or fatigues professionals
  8. Physical & emotional issues
  9. Poor communication between doctor & patient
  10. Physicians who are drunk or on illicit drugs
  11. Poor handwriting
  12. Patients:
  13. Patient’s literacy, attitude, language etc.
  14. Not disclosing complete details of their disease
  15. Not revealing the ongoing treatment including OTCs
  16. Failure to read drug label carefully
  17. Non-compliance with treatment and financial issues
  18. Malingering cases to get favour in the job  
  19. Complexity of disease
  20. Multiple diseases
  21. Multiple drugs
  22. Environment:
  23. Time pressure
  24. Distraction & interruptions by staff
  25. Lack of standard operating procedures (SOPs)
  26. Inadequate resources
  27. Poor patient record
  28. Inappropriate ordering, processing and authorization

Besides medication errors involving drugs and prescriptions, the following medical errors can also be taken with a serious note.

  1. Errors in Surgery: Amputating the wrong limb, leaving instruments in the body etc.
  2. Diagnostic errors: Wrong diagnosis thus prescribing wrong treatment. It also include failure to use right diagnostic tests, misinterpretation of test results.
  3. Equipment failure: Poor function of IV pumps pushing wrong doses, dead batteries in defibrillator posing life risk at the time of emergency.
  4. Poor infection control in the hospital: Frequent occurrence of post-surgical infection, nosocomial infections and infection due to multidrug resistant pathogens.
  5. Blood transfusion related injuries: Incompatible blood transfusion, improper screening of blood for HIV, HBV, HCV and others.    

Besides there are errors of omission that harm the patient by not doing the same eg, lack of follow up in serious illnesses, delay in proper diagnosis, failure to suggest preventive care.    

Some of the interesting case reports published in leading journals on medication errors:

  1. A 71 years old female was prescribed Norvasc (amlodipine) for hypertension but received Navane (thiothixene) for psychosis for 3 months despite interacting with multiple areas of the health care system.
  2. A hand written prescription of Rythmol (propafenone) in a 73 old patient for cardiac arrythmia was receiving Synthroid (levothyroxine) used for hypothyroidism.
  3. A 50 year women in the hospital setting was accidently administered adrenaline in place of midazolam. The procedure was required to be postponed for several days till the patient recovered.
  4. A cluster of 5 adult patients unintentionally  received Insulin instead of influenza vaccine. All 5 patients developed acute hypoglycaemia with varying degree of symptoms.
  5. Warfarin and Rivaroxaban (both anticoagulants) were administered concurrently

The above are just few examples to indicate the severity of error that can be even fatal. In routine clinical settings there are multiple cases that remain unnoticed and never come to public or even treating physician. There has to be diligent continuous efforts to minimize such errors to provide best healthcare solution to the patients.

There should be continuous focus on health system strengthening and review of the procedures and trainings. Some of the following strategies can be prioritize to set the goal.

  1. Educating Health care providers & patients.
  2. Implementing medication reviews & reconciliation
  3. Use of computerized system

Prioritizing areas of quick win eg. Injections, children, elderly