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Medication Errors

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Medication Errors

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tablets spilling out of bottleWhat’s the true incidence of medication errors? No one really knows. A study of two Australian hospitals shed a little more light on medication errors – what kind were made and which were reported. The researchers found very few medication errors were reported versus that that were committed. The findings were based on medication errors that occurred in two large teaching hospitals in Sydney, Australia.

1. Researchers studied 3,291 medical records to detect prescribing errors and evidence that the staff detected these errors.

2. They observed 180 nurses giving medications and making errors.

3. They reviewed incident reports to see if the prescribing and administration errors were detected or reported.

Medication Errors Conclusions

Of the two hospitals, the one that had the higher number of incident reports (compared to the other hospital) had lower “actual” prescribing errors. The hospital with staff who did not detect or report errors with the same frequency had higher “actual” number of errors.

Of the 12,567 prescribing errors totaled from both hospitals, 4.3% of the prescribing errors were clinically important (likely to lead to patient harm). Although the staff detected a little more than one-fifth of these errors, only 1.3% were reported through the incident reporting system. Most of the medication administration errors were procedural, such as not confirming the patient’s identity before giving the medication; 10% of the clinical errors were significant with the potential for causing harm to the patient. None of these errors were reported. Read more at http://www.healthcanal.com/public-health-safety/61566-study-medication-error-reporting-not-indicative-of-patient-safety.html

Medication Errors Reporting

What can we conclude about medication error reporting? First, there are a lot of errors that are not detected or reported. You are an attorney handling a medication error case and ask for an incident report. “None exists”, you’re told. You might get this answer because:

1. The facility management has a “shame and blame” mentality. Staff are afraid to report errors, despite all of the work of the risk management experts who emphasize the need to foster a Just culture without fear of reprisals.

When I was a nursing quality assurance coordinator, I sat in a Pharmacy and Therapeutics Committee meeting and listened to a doctor demand the director of nursing explain each of the 6 incident reports for the month. This was a 600 bed hospital – and nurses reported only 6 errors? Really? When I talked to the Vice President for Nursing, I asked about the policy on incident reports. “What happened to the nurse who reported an error?” She explained, “We give them education or discipline. After the nurse reports 3 errors, we fire the nurse.”

The VP wondered why people did not report errors. When I said to her, “Our nurses are not reporting errors because of the consequences”, she shook her head “no” and asserted that they would report anyway. I don’t think so.

2. The error was not detected at the time. In the Australian study, 78% of the prescribing errors were not detected, or the medical record did not show that they were detected. If the errors were not detected, this raises questions about the adequacy of the safety net.

• Was there an electronic medical record with alerts to warn of orders that would create an unsafe situation, such as giving a contraindicated medication, one to which the patient was allergic, or was incompatible with other medications that patient was on?
• Did the prescriber override the alerts because of alert fatigue (too many annoying warnings results in the prescriber clicking through and ignoring the warnings)?
• Did the pharmacy fail to note the error?
In this study, 539 of these clinically important errors slipped through the safety net.

Medication errors causes an estimated $21 billion in medical costs. There are 7 million annual inpatient admissions and outpatient visits involving serious medication errors that are potentially avoidable. Are these real numbers? Accurate? No one really knows.

Need a chronology for your medication error case? Our inhouse nurses are at your service. Contact us for assistance.

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