Medication errors

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A medication error is any unintentional mistake by a healthcare professional , patient, or consumer in prescribing, preparing, dispensing, or administering a drug . Medication errors can, but need not, lead to avoidable adverse drug events.

definition

According to the US National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), a medication error is defined as follows:

“A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use ”

According to this definition, a medication error is avoidable in any case, can occur in the entire medication process and can, but does not have to, lead to harm to the patient.

The European Medicines Agency defines medication errors as follows:

“Medication errors are unintentional errors in the prescribing, dispensing, administration or monitoring of a medicine while under the control of a healthcare professional, patient or consumer. They are the most common single preventable cause of adverse events in medication practice. "

According to this definition, a medication error is unintentional and can occur in the entire medication process.

Based on these definitions, the drug information systems working group of the German Society for Medical Informatics has defined a medication error as follows:

"Any unintentional mistake by a healthcare professional, patient, or consumer in prescribing, preparing, dispensing, or administering a drug."

If the medication error is the responsibility of a doctor and occurred in violation of the rules of medical art, there may be a medical treatment error.

A review found 26 different definitions of medication errors in the scientific literature.

The large number of definitions used, as well as the use of different detection methods, make it difficult to compare the frequency of medication errors.

Occurrence and causes

Medication errors can occur at any stage of the medication process (see illustration). Most common are errors in the prescription, such as: B. double prescriptions, failure to take into account necessary dose adjustments, overlooked contraindications or interactions or simply reading errors, followed by errors in application or ingestion.

The six stages of the medication process

An analysis of 2,103 medication errors in a 630-bed hospital found the following factors that contributed to the medication error:

  • Lack of or incorrect knowledge about drugs and their use (e.g. double prescriptions, wrong drug, wrong route, wrong duration of use, interactions): 30%
  • Missing or incorrect knowledge about the patient and his or her history (e.g. physiological status, allergies , contraindications , medical history , incorrect patient): 29%
  • Incorrect calculations (e.g. calculation error, error with decimal point): 18%
  • Problems with the nomenclature (e.g. soundalike , abbreviation errors ): 13%
  • Dosage error (e.g. incorrect dosage ): 3%
  • Administrative processes (e.g. transferring data): 3%

frequency

Medication errors are common. A systematic review, which included 63 studies from 1985 to 2007, showed that, on average, errors were discovered in 7% of all medication orders in the hospital sector and that every second hospital admission was affected. Another systematic review, which included 52 studies from 1966 to 2011, found that a median of 10.5% of all medication orders found errors in the hospital setting.

recognition

There are several ways to identify medication errors and determine their frequency and severity:

  • Direct observation of prescription processes
  • Manual analysis of prescriptions including clinical data (chart review)
  • Automatic analysis of prescriptions using clinical data
  • Evaluation of voluntary reporting systems regarding reported medication errors
  • Interviewing clinical staff
  • Interviewing the patient

The methods differ in the necessary requirements (e.g. electronic drug documentation), the detection rate and the effort involved. Direct observations are more time-consuming but more sensitive than manual chart reviews, and these in turn are more sensitive than the analysis of reporting systems. Direct observations are particularly suitable for the detection of errors in dispensing and application or ingestion, while chart reviews are suitable for the detection of prescription errors and resulting patient harm.

Avoidance

Medication errors can of awareness among patients and physicians, better communication between patient and doctor, better preparation of technical information for the physician incorporating by strengthening pharmacists in the visit , providing information about pre-existing conditions and premedication of the patient as well as building safety culture be reduced.

In addition, the possibilities of reducing medication errors through the use of information technology in all phases of the medication process have recently been discussed. Examples of information technologies to support the medication process and to reduce medication errors are:

Taxonomy

The National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) is the publisher of a Taxonomy of Medication Errors. This taxonomy represents a standardized language and structure for the description and analysis of medication errors. It contains the essentially structured description of the following information:

  • Patient information, e.g. B. Initials, age, gender
  • The event (The Event) z. B. Date, time, clinical setting, description of the event (the latter as the only element as free text)
  • Patient outcome, with the following categories, each of which includes further sub-categories:
    • No Error (conditions that could have led to an error)
    • Error, no Harm (An error occurred, but no damage occurred)
    • Error, Harm (An error has occurred and damage has occurred)
    • Error, Death (An error occurred and a patient died)
  • Product information, i.e. information on each medication involved (e.g. name, dose)
  • Personnel involved, i.e. information on each employee involved (especially professional group)
  • Type of error (Type), with the following subcategories:
    • Missing a dose (Dose Omission)
    • Wrong dose (improper dose)
    • Wrong Strength / Concentration
    • Wrong Drug
    • Wrong Dosage Form
    • Wrong Technique
    • Wrong Route of Administration
    • Incorrect frequency (wrong rate)
    • Wrong Duration
    • Wrong Time
    • Wrong patient
    • Monitoring error (e.g. interaction, allergy, contraindication)
  • Causes, with the following categories, which are divided into further sub-categories:
    • Communication, e.g. B. Verbal transmission errors, illegible handwriting, unclear abbreviations
    • Name confusion, e.g. B. Confusion with another drug (sound-alike or look-alike with regard to the drug name)
    • Labeling, e.g. B. Confusion of similar packaging, missing product information
    • Human factors, e.g. B. Knowledge deficit, incorrect dose calculation, errors in preparation of the drug, transfer errors, stress, tiredness
  • Contributing factors (systems related), such as B. Noise, training, processes

Individual evidence

  1. ↑ a b c d e f g h i E. Ammenwerth, AF Aly, T. Bürkle, P. Christ, H. Dormann, W. Friesdorf, C. Haas, WE Haefeli, M. Jeske, J. Kaltschmidt, K. Menges, H. Möller, A. Neubert, W. Rascher, H. Reichert, J. Schuler, G. Schreier, S. Schulz, HM Seidling, W. Stühlinger, M. Criegee-Rieck: On the use of information technology to improve Drug Therapy Safety (Memorandum AMTS-IT) . In: GMS Med Inform Biom Epidemiol. 10 (1), 2014, Doc03.
  2. ^ National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP): What is a medication error? . Accessed December 31, 2014.
  3. ^ European Medicines Agency. Medication Errors . Accessed December 31, 2014.
  4. ↑ a b c M. Lisby, LP Nielsen, B. Brock, J. Mainz: How are medication errors defined? A systematic literature review of definitions and characteristics. In: International Journal of Quality in Health Care. 22 (6), 2010, pp. 507-518.
  5. ↑ DW Bates, DJ Cullen, N. Laird, LA Petersen, SD Small, D. Servi, G. Laffel, BJ Sweitzer, BF Shea, R. Hallisey, MV Vliet, R. Nemeskal, LL Leape, for the ADE Prevention Study Group: Incidence of adverse drug events and potential adverse drug events - Implications for prevention ( Memento of the original from March 4, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. . In: Journal of the American Medical Association 274 (1), 1995, pp. 29-34. @1@ 2Template: Webachiv / IABot / ptsafetyresearch.org
  6. ↑ TS Lesar, L. Briceland, DS Stone: Factors related to errors in prescribing medication. In: Journal of the American Medical Association. 277 (4), 1997, pp. 312-317.
  7. ^ PJ Lewis, T. Dornan, D. Taylor, MP Tully, V. Wass, DM Ashcroft: Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. In: Drug Safety 32 (5), 2009, pp. 379-389.
  8. ↑ S. Berdot, F. Gillaizeau, T. caruba, P. Prognon, P. Durieux, B. Sabatier: Drug administration errors in hospital inpatients: a systematic review . In: PLOS ONE . 8 (6), 2013, p. E68856.
  9. ↑ a b c E. A. Flynn, KN Barker, GA Pepper, DW Bates, RL Mikeal: Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. In: American Journal of Health-System Pharmacy . 59 (5), 2002 Mar 1, pp. 436-446.
  10. ↑ a b T. Morimoto, TK Gandhi, AC Seger, TC Hsieh, DW Bates: Adverse drug events and medication errors: detection and classification methods. In: Quality and Safety in Health Care. 13 (4), 2004, pp. 306-314.
  11. ↑ RR Benkirane, R. Abouqal, CC Haimeur, SS Secek, AA Azzouzi, AA M'Daghri Alaoui include: Incidence of adverse drug events and medication errors in intensive care units: a prospective multicenter study. In: Journal of Patient Safety. 5 (1), 2009, pp. 16-22.
  12. ↑ WO Hackl, E. Ammenwerth, R. Marcilly, E. Charzard, M. Luyckx, P. Leurs, R. Beuscart: Clinical evaluation of the ADE scorecards as a decision support tool for adverse drug event analysis and medication safety management. In: British Journal of Clinical Pharmacology . 76 (Suppl S1), 2013, pp. 78-90.
  13. ^ R. Desai, CE Williams, SB Greene, S. Pierson, RA Hansen: Medication errors during patient transitions into nursing homes: characteristics and association with patient harm. In: The American Journal on Geriatric Pharmacotherapy. 9 (6), 2011, pp. 413-422.
  14. ↑ LL Leape, DW Bates, DJ Cullen, J. Cooper, HJ Demonaco, T. Gallivan et al: Systems analysis of adverse drug events. ADE Prevention Study Group. In: Journal of the American Medical Association. 274 (1), 1995, pp. 35-43.
  15. ↑ a b c D. Grandt, C. Braun, W. Hauser: Frequency, relevance, causes and strategies for avoiding medication errors. In: Journal of Gerontology and Geriatrics. 38, 2005, pp. 196-202.
  16. ↑ a b c d Institute of Medicine Preventing Medication Errors . The National Academic Press, Washington DC 2007.
  17. ^ PM Cox, Jr., S. D'Amato, DJ Tillotson: Reducing medication errors. In: American Journal on Medical Quality. 16 (3), 2001, pp. 81-86.
  18. ^ National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP). Taxonomy of Medication Errors . 1998. Accessed December 31, 2014.