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medication errors

Etiology: 1) medication delivery device 2) misspellings 3) clerical errors 4) unintentional discontinuation of medications [3] 5) clinician fatigue, overcrowding, staff shortages, improper training, & incorrect information cited as risk factors for medication errors [7] Epidemiology: - 25% of insulin errors lead to patient harm [5] - insulin is involved in ~ 1/3 of fatal medication errors [5] Management: - measure & record weight in kilograms only [8] - 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 [8] Notes: - medication errors will be reduced by electronic prescribing, but will present new challenges - pharmacy led intervention can reduce medication errors in primary care [4] - medications errors common after hospital discharge [6] - 50% discordance between hospital discharge medication lists & patients' self-reported medications [6] - World Health Organization (WHO) has launched campaign to reduce medication errors by 1/2 within the next 5 years [7] - estimated global cost = $42 billion annually [7]

Related

medication reconciliation

General

pharmacology

References

  1. Prescriber's Letter 12(12): 2005 Medication Errors and Patient Safety Resources Detail-Document#: 211201 (subscription needed) http://www.prescribersletter.com
  2. Prescriber's Letter 14(1): 2007 Medication Errors due to Medication Delivery Devices Detail-Document#: 230113 (subscription needed) http://www.prescribersletter.com
  3. Bell CM et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA 2011 Aug 24/31; 306:840 PMID: 21862745
  4. Avery AJ et al. A pharmacist-led information technology intervention for medication errors (PINCER): A multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet 2012 Feb 21; PMID: 22357106 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61817-5/fulltext
  5. Prescriber's Letter 21(7): 2014 Tips to Improve Insulin Safety Detail-Document#: 300713 (subscription needed) http://www.prescribersletter.com
  6. Mixon AS et al. Characteristics associated with postdischarge medication errors. Mayo Clin Proc 2014 Aug; 89:1042 PMID: 24998906
  7. World Health Organization (WHO). News Release. March 29, 2017 WHO launches global effort to halve medication-related errors in 5 years. http://www.who.int/mediacentre/news/releases/2017/medication-related-errors/en/
  8. Benjamin L, Frush K, Shaw K et al Pediatric Medication Safety in the Emergency Department. Pediatrics. March 2018, VOLUME 141 / ISSUE 3 PMID: 29458814 http://pediatrics.aappublications.org/content/141/3/e20174066 - Benjamin L, Frush K, Shaw K et al Pediatric Medication Safety in the Emergency Department. Ann Emerg Med. 2018 Mar;71(3):e17-e24. PMID: 29458814