Medication Dispensing Errors and Prevention

Excerpt

Medication errors are the most common and preventable cause of patient injury. These errors typically involve administering the wrong drug or dose, using the wrong route, administering it incorrectly, or giving medication to the wrong patient. The reported incidence of medication errors in acute hospitals is approximately 6.5 per 100 admissions.

The Institute of Medicine (IOM) Committee on Quality of Health Care in the United States defines an "error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." The IOM identifies medical errors as a leading cause of death and injury. According to the 2019 World Health Organization (WHO) factsheet on patient safety, adverse events resulting from unsafe patient care rank among the top 10 causes of death and disability worldwide. In the United States of America, preventable adverse events lead to an estimated 44,000 to 98,000 hospital deaths annually, surpassing the number of deaths attributed to motor vehicle accidents. These events are estimated to cost between 37.6 to 50 billion dollars of added health care costs, disability, and lost productivity.

To comprehensively assess the true impact of medication errors in the healthcare industry, one must become familiar with the nomenclature used to describe events associated with medication errors. The following is an overview of the typical terminology used in medical literature to describe events associated with medication errors.

Adverse Drug Reaction (ADR)

As defined by the World Health Organization, an ADR is a harmful, unintended reaction to a medication occurring at normal treatment doses.

Adverse Drug Event (ADE)

An Adverse drug event is a broader term encompassing any harm resulting from medication, including harm from the drug at a standard dose and harm due to inappropriate dosage or overdose.

Medication Misadventure

A medication misadventure is any iatrogenic incident or hazard associated with medication. Medication misadventures include medication errors, adverse drug reactions, and adverse drug events.

Sentinel Event

The Joint Commission defines a sentinel event as "an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof." Serious injury means the loss of a limb or function and encompasses any process variation where a recurrence would carry a significant chance of a serious adverse outcome. Sentinel events may involve medication errors, adverse drug events, and medication misadventures. Importantly, sentinel events are not limited to medication-related errors but can result from any clinical care process mistake, including surgical, diagnostic, and treatment errors.