Can Medication Errors Be Avoided?

Patients are supposed to feel safe under treatment and healthcare professionals are supposed to feel confident in performing their job. Unfortunately, study after study presents a different reality in the chain of care.

Medication errors are common, costly and many times quite catastrophic. The human factor must always be taken into consideration, and after all, healthcare is about humans treating other humans. But these mistakes come to a (literally) high price and we need to do everything in our power to avoid them. We need to do more. And we can.

There’s not one isolated element that leads to medical errors. There are actually several sources for these errors. According to the Institute for Safe Medication Practices (ISMP), they are:

  • patient information
  • drug information
  • adequate communication
  • drug packaging, labeling, and nomenclature
  • medication storage, stock, standardization, and distribution
  • drug device acquisition, use, and monitoring
  • environmental factors
  • staff education and competency
  • patient education
  • quality processes and risk management.

The environmental factors
Let’s take a closer look at the environmental factors, which often cause mistakes. Healthcare equals workload under high pressure and physicians, nurses and staff often need to make rapid decisions. Here are just a few possible scenarios where things go wrong:

  • A physician’s handwriting can easily be misread, leading the pharmacist to fill the order with the wrong dosage or even the wrong medication. If it’s a longterm treatment and the wrong order keeps being refilled, it can lead to a fatal outcome in the end. This has happened many times before.
  • Distraction in the room can lead to flaws during the preparation of a drug. Therefore, many hospitals have introduced no interruption-zones around the dispensing space as a safety prevention. A great way to enhance patient safety — but is it enough?
  • Heavier workload and increased responsibility are also an environmental risk factors. In today’s healthcare, nurses are often responsible for a great number of patients and are also expected to perform tasks beyond their initial routines. When the safety standards are jeopardized due to stress, it can cause harm to the patient as well as the caretaker who becomes a ”second victim”.

A recent report from Swedish hospital
In August, a child patient under treatment at Skåne University Hospital got a ten times too high dose of morphine. The cause was a mix-up between milligrams and milliliters.

The patient wasn’t harmed by the incident, but adequate measures were taken due to the fact that it could have caused serious damage. The case was later closed without further action. A new program in the patient record system adapted especially for children will now be introduced and new procedures for drug prescriptions is expected to be implemented in January next year.

The fact that the healthcare industry keeps on improving the safety standards is great. However, the problem with medication errors is still far from solved. Only in the USA, the cost each year is measured to several billion dollars. There is a huge incentive to find better solutions to the problems with medication errors. Money is hardly the big issue here.


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