Posted by Bill Sandweg on 05 April 2021.
Medication errors can and do kill and injure patients in hospitals, outpatient clinics and as a result of doctor ordered prescriptions. There are literally thousands of medications, which can be prescribed for patient use. Many have confusing names. Many have names which are very similar to those of other medications. Many come in various dosage strengths. In short, there are lots of ways to make mistakes in medication administration.
People prescribe medications, fill prescriptions, issue medications in hospitals and deliver them to patients and people make mistakes. The sheer number of medications, their similarities and their varying doses make human error in medication administration almost a certainty.
Medication errors can occur in local pharmacies where we get our prescriptions filled. I have represented patients, and sometimes the surviving family members of patients, who have been the victims of pharmacy malpractice. One case involved a woman who was receiving an opioid medication and the pharmacy accidentally gave her a pill with two times the correct amount of the opioid. She died of an overdose when she took what the pharmacy gave her. I have represented patients in cases where the pharmacy dispensed a drug with a similar name but which was intended for a completely different condition. Fortunately, that patient survived.
Although it is easier said than done, always check your prescription when you get home before taking the medication. Is it the correct medication? Is it the dose the doctor ordered? Is it a medication for a condition you have? Today, anyone with access to the internet can look up a medication and pretty quickly see if it is a medication for a condition they have or not. This is a big advance over past years and one we should take advantage of.
Those who study medication errors say that the least effective way to address medication errors is through education. There is just too much information for the human brain to comprehend. It is too easy to forget or to be distracted or to be overwhelmed. They say the best way to prevent medication errors is through the use of technology.
Computers may not be smarter than we are but once properly programmed, they never forget, never get distracted and never get overwhelmed.
Computers can be programmed to recognize when a patient has been given a drug which will combine with another drug they are already taking. Sometimes, the two drugs will address the same condition and their effects will be added to each other resulting in too much medication. Sometimes, the two drugs interact in other ways which is damaging to the patient.
Infusion pumps are smart today as well. They can be programmed not to permit overdoses and to correct other errors in administration. The big problem appears to be getting hospitals to use the best available pumps with the best available safeguards.
As is always the case, human communication remains a fertile area for mistakes, which may affect medications. The first malpractice case I was ever involved with had to do with a misplaced decimal point. The order was for .05 mg of a highly toxic medication. The nurse at the hospital misread the order and administered .5 mg, 10 times the intended dose. The infant patient suffered a devastating brain injury. A computer would have recognized the dangerous dose. The misplaced or missing decimal point is a frequent cause of medication errors.
Poor handwriting accounts for many errors. Doctors are no better than the rest of us when it comes to poor handwriting. The difference is my poor handwriting is unlikely to cause serious injury.
Errors also arise from the habit of doctors to use symbols or abbreviations. At least one study found that 5% of medication errors were the result of using an abbreviation, which was misinterpreted by the person actually administering the medication. Leaders in healthcare have been encouraging the banning of abbreviations for years, with only mixed results.
The conclusion is that medication errors are common but that technology has the ability to make them less frequent. There is little you can do when you are in the hospital to guard against medication errors. Do, however, make sure when the come to give you a medication that they have the right person and that it is a medication you are supposed to be taking.