Medication Errors

Medication errors remain one of the leading causes of injuries and deaths in hospitals. These incidents occur in several, different scenarios.

Medication dosage errors are the most common. It can be particularly dangerous when a decimal point describing the dose is placed in the wrong location. For example, suppose a doctor writes a prescription for Colchicine. Instead of ordering the intended dose of “1.0 mg,” he accidently writes or orders “10.0 mg,” resulting in the patient getting ten times the dose prescribed. This decimal error can have catastrophic consequences for the patient. The higher dose could lead to Colchicine poisoning, which is similar to arsenic poisoning. The patient’s internal organs could shut down and the patient would likely die within twenty-four to seventy-two hours.

Mistaken medication types are another common form of medication error. The names of some drugs are very similar to others, and a pharmacist or hospital nurse can mistake one drug for another, leading to the patient receiving the wrong medication.

Another form of medication error occurs when a medication is contraindicated because of the patient’s condition, or because of other medications that the patient is taking. For example, there are certain medications that are not recommended for pregnant women. There are also medications that are not recommended for patients who have certain diseases. There are also medications for which it is recommended that they not be taken in combination with other medications or if they must be taken together, the patient should be monitored closely. For example, individuals who take Coumadin (a blood thinner) should not be prescribed certain types of antibiotics without having the prothrombin time (PT/INR) monitored on a daily basis to ensure that the two medications taken together are not causing excessive internal bleeding.

A less frequent but potentially dangerous type of medication error occurs when a medication order for one patient is placed in the chart of another patient. Hospitals should have medication reconciliation protocols in place to detect such errors before the patient is adversely affected. However, if undetected, the patient receiving the wrong medications over an extended period of time can suffer severe, adverse consequences. We represented an individual who was taken to the emergency room during the weekend because she was experiencing a cardiac condition known as atrial fibrillation. The emergency room physician examined the patient, consulted with the patient’s cardiologist, and the decision was made to admit the patient to the hospital for monitoring. Unfortunately, at the same time that our client was seen in the emergency room, another patient who had significant psychiatric illnesses was admitted to the emergency room and examined by the same emergency room physician. After examining both patients, the emergency room physician placed a medication order that was intended for the psychiatric patient in the chart of our client, who had no history of any psychiatric illnesses. This resulted in our client being given potent antipsychotic and antidepressant medications over the next four days. These medications had multiple, well-known side effects including dizziness, drowsiness, weakness, blurred vision, confusion and fainting. On the fourth day in the hospital, our client was so drowsy, weak and confused from the medications that had been given to her in error that she fell and suffered a closed head injury and fractured vertebrae. We characterized that case as a “system failure case,” meaning that the entire system, from the emergency room doctor to the patient’s attending physician to the nurses and staff at the hospital, failed to detect the medication error.

The number of people injured and killed by medication errors, and the cost of such errors, are staggering. Consider the following:

• 1.5 million patients are harmed by medications each year.

• 100,000 people die each year as a result of medication errors.

• 400,000 medication-related injuries occur each year in hospitals. That means there is approximately 1 medication error per patient every day.

• It has been estimated that injuries caused by medication errors result in $3.5 billion in additional medical costs.

Considering the staggering numbers of injuries and deaths, and the costs associated with medication errors, it is important that there be organizational policies, procedures and systems in place for ordering, dispensing and administering medications that are designed to minimize errors. These policies and procedures should be established system-wide, so that they apply to the management of the hospitals, and to the physician prescribers, pharmacists, nurses and others. When there is a breakdown in the system and a patient suffers serious injuries due to a medication error, such as the case described above, the wrongdoers should be held accountable.