Top 10 Medications Involved in Drug Errors
The following list represents the medications which are involved in medication errors by healthcare professionals. This list is based on information from the United States Pharmacopoeia (USP), which maintains a database of medication errors that are reported anonymously. The following represent drug errors associated with acute hospital care:
Insulin (4% of all medication errors in 2005);
Potassium chloride (2.2%);
Warfarin (1.4%); and
The USP database is used by healthcare facilities to track medication errors and identify common trends. A medication error is defined as an " unintentional act committed by healthcare providers involving medications".
Insulin is the number 1 culprit in med errors by healthcare professionals. The errors include incorrectly mixing up the products with similar packaging; confusing generic listings on computer databases; names similarities (eg, Humalog and Humulin); and most importantly, confusing the abbreviation "u" for units with the number 0. These errors have been occurring for decades and as healthcare professionals we owe it to our patients to be aware of this information in order to do our part in helping control medication errors.
Morphine is another medication that is often confused with others.
Morphine and hydromorphone;
Oxycontin and MS Contin;
Hydrocodone and oxycodone
Oxycodone and codeine.
Many times in Pharmacies these opiods are stored together
and confused with one another or, since they are stacked
together it can be easy to grab the wrong one by mistake.
The prescription for "qid" (4 times daily) instead of "qd"
(once daily), has caused fatal and near-fatal overdoses.
Acetaminophen is available in many different strengths.
Prescription labels of combination products with aceta
-minophen can be confusing to many patients. For example,
hydrocodone 10/500 has 500 mg of acetaminophen, but
many patients would not know how to interpret that.
Although acetaminophen is sol OTC it can still be toxic.
Antibiotics are the next big group of drugs associated
with medication errors.
Reconstituting antibiotics can also be problematic.
Pharmacists have mistakenly reconstituted antibiotic
suspensions with alcohol instead of distilled water.
System Errors May Interfere With Individual Efforts
Most healthcare professionals have learned the "5 rights" of safe medication use: the right patient, the right drug, the right time, the right dose, and the right route of administration. But now we are in the midst of the computer age. Do we rely on computers too much? not thinking about the chance that there can be errors here too and in turn forgoing the "five rights"?
Here is the information we should think about as nurses before we administer any medication.
Patient information (age, weight, allergies, diagnoses, and pregnancy status);
Drug information (up-to-date information readily available);
Communication (collaborative teamwork between all healthcare members and the patient);
Drug labeling, packaging, and nomenclature (limit look-alike and sound-alike drug names, confusing packaging);
Drug standardization, storage, and distribution (restricting access to high-alert drugs);
Medication delivery device acquisition, use, and monitoring;
Environmental factors (poor lighting, cluttered work spaces, noise, interruptions, nonstop activity, and deficient staffing);
Staff competency and education;
Patient education; and
Quality processes and risk management (systems are needed for identifying, reporting, analyzing, and reducing the risk for medication errors with a non-punitive culture of safety).
It can be tempting to blame others for our mistakes when medication errors occur. But instead of playing the "blame game", let’s instead look at why the error occurred as a whole system. For example, are the work schedules in the facility within reason? Is the facility understaffed? Is there enough training and in-service provided? These are the questions we must ask, if we are to lower the incidence of errors in the future.
How Can We Prevent Medication Errors?
Most medication errors can be prevented and there are common scenarios that most likely lead to an adverse event. These scenarios include:
Failure to detect a disease state contraindication to the drug therapy;
Failure to detect a significant drug interaction;
Failure to detect a significant drug allergy;
Failure to prescribe the correct dose for a specific patient;
Failure to monitor drugs with narrow therapeutic indexes; and
Patient knowledge deficits.
So what can we do to prevent these types of errors? Communication, communication, communication.
Just a few minutes of counseling between the prescriber and the patient can save a world of headaches,
paper work, unnecessary trips to the ED and possibly fatality. If you cannot read an order then contact the
prescriber and verify and confirm what you "think" it may say before it is administered to the patient.
Handle conflicting ideas regarding patients care with professionalism and be objective. Remember, this
isn't about how well you like "Mary " the nurse in the other unit, it's about the safety and welfare of our
patients. We are their advocates and they rely on us.