1. What Is A Medication Error?

A medication error is any preventable event that may cause or lead to inappropriate medication use or harm to a patient.  According to the article by Aronson, “Medication errors: what they are, how they happen, and how to avoid them” (Quarterly Journal of Medicine, 2009):

A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. Medication errors can occur in:

• deciding which medicine and dosage regimen to use (prescribing faults–irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing);
• writing the prescription (prescription errors);
• manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging);
• dispensing the formulation (wrong drug, wrong formulation, wrong label);
• administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration);
• monitoring therapy (failing to alter therapy when required, erroneous alteration).”  

A study by the FDA that evaluated reports of fatal medication errors from 1993 to 1998, the most common error involving medications was related to administration of an improper dose of medicine, accounting for 41% of fatal medication errors. Giving the wrong drug and using the wrong route of administration each accounted for 16% of the errors.

2.   Some Alarming Facts and Statistics

• Although the number of reported errors is frighteningly high, these numbers may represent only a small portion of the actual errors. Many patients do not realize that an error occurred and therefore cannot report it. Health care professionals often fear retribution for medication errors, so they hide the fact that an error occurred. (Lauren Schlesselman, PharmD, “10 Strategies to Reduce Medication Errors”, https://secure.pharmacytimes.com/lessons/200809-01.asp)
• In the IOM 2006 report, “Preventing Medication Errors”, it was found that naming, labeling, and packaging accounted for 33% of medication errors, including 30% of fatalities (http://www.iom.edu/Reports/2006/Preventing-Medication-Errors-Quality-Chasm-Series.aspx).
• According to Budnitz et al., “National Surveillance of Emergency Department Visits for Outpatient Adverse Drug Events” (JAMA, 2006), more than 700,000 patients were treated in emergency departments for ADEs in 2004-2005. Of these visits, one third was attributed to allergic reactions; another one third was due to unintentional overdoses. (http://jama.jamanetwork.com/article.aspx?articleid=203690)
• From the United States Pharmacopeia (USP) reports, nearly 200,000 medication errors were documented in MEDMARX in 2002. More than 3000 of these errors resulted in patient injury; 514 required initial or prolonged hospitalization, 47 required interventions to sustain life, and 20 resulted in a patient’s death (http://www.usp.org/).
• According to the Institute of Medicine 2006 report, “Preventing Medication Errors”, medication errors harm about 1.5 million people in the US each year. This results in about $4 billion in extra medical costs. (http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf)
• More discussions about this IOM report can be find in this 2006 article published by the Washington Post (httpw://www.washingtonpost.com/wp-dyn/content/article/2006/07/20/AR2006072000754.html)
• According to the study by Dr. Barbara Starfield, there are 7000 deaths/year from medication errors in hospitals; 106,000 deaths/year from non-error, adverse effects of medications.  This will result in $12 billion of extra medical costs. (Starfield B. Is US health really the best in the world? JAMA. 2000 Jul 26;284(4):483-5;  Starfield B. Deficiencies in US medical care. JAMA. 2000 Nov 1;284(17):2184-5; Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205; Suh DC, Woodall BS, Shin SK, Hermes-De Santis ER. Clinical and economic impact of adverse drug reactions in hospitalized patients. Ann Pharmacother. 2000 Dec;34(12):1373-9.)
• Based on an analysis of 2011 ADE reports to FDA, about 2 to 4 million people suffered serious, disabling, or fatal injury associated with prescription medication.
• In 2011, the FDA received about 180,000 reports of serious, disabling, and fatal ADE in the US.   But, less than 1% of all serious adverse events are actually reported, according to the FDA estimates. (http://www.ismp.org/quarterwatch/)
• Elderly typically take more medicines and are twice as likely as others to come to emergency departments for adverse drug events (over 177,000 emergency visits each year) and nearly seven times more likely to be hospitalized after an emergency visit. (http://www.cdc.gov/MedicationSafety/Adult_AdverseDrugEvents.html)
• Elderly are at greatest risk for medication errors because they often take multiple prescription medications.  Almost half of the fatal medication errors occurred in people over the age of 60.
• On average, elderly take about 10 medications. Because of that, plus their compromised health conditions and different body rate to absorb and process medications, elderly are at an increased risk of being harmed by medication errors.
• About 2 million ADEs occur each year in long-term care facilities in the United States; 42% (800,000) are preventable. (Crespin et al., The American J. of Geriatric Pharmacotherapy, 2011, doi:10.1016/j.amjopharm.2010.05005, 258-270).
• Among the 42% of medication errors in long-term care facilities, 11% related to wrong dose; 27% related to the medication itself; 11% to the preparation; and 57% to the timing (Zimmerman, et al., JAGS, 59:1060-1068, 2011).
• A study of 18 community-based nursing homes in Massachusetts found that preventable medication errors occurred at a rate of ~1/100 residents/month, and ~60% of the events were fatal, life-threatening, or serious. (Crespin et al., The American J. of Geriatric Pharmacotherapy, 2011, doi:10.1016/j.amjopharm.2010.05005, 258-270).

 3.  Medication errors are preventable, if basic, simple steps are followed:

For healthcare providers, one should follow the basic check and double check:

• Right medication
• Right dose
• Right person
• Right route
• Right time
• Right documentation

For patients, one should not assume the prescribing physician knows about the drug risks and benefits specific to you. Always be alert and take an active role:

• Know the names of your drugs and why they are prescribed
• Ask questions about the recommended drugs. Do not make assumptions.
• Read drug labels & follow directions
• Inform doctors your knowledge and concerns
• Demand two-way communications
• Keep a list of all your medications
• Be the final arbitrator of the final decision

4.  Be Proactive and Protect You and Your Loved Ones from Medication Errors and Harm

See these good tips on Empowered Patient Coalition website

This site also has other helpful information on Medication Safety

Tips from Agency for Healthcare Research and Quality

Some helpful information by MayoClinic.com

5.  Be Informed

As patients, educating ourselves is a great way to help communicate with doctors about medications and to avoid errors and harm. Here are some good websites for medication information:

Drugs, Supplements, and Herbal Information on MedlinePlus

Drug information on RxList

Drug information on WebMD

FDA Drug Information

Medication Information on Access Pharmacy

6.   Report Adverse Drug Events

MedWatch: The FDA Safety Information and Adverse Event Reporting Program

The Institute for Safe Medication Practices