news report of patient med errors made at home

What causes medication errors in home care?

A lack of competence in healthcare workers can also lead to medication errors. To prevent these, it is important that there should be up-to-date information and communication between healthcare workers during the transfer of patients from specialist to home care.

Where can I find information about medical errors?

The National Center for Biotechnology Information, “Medication Errors.” Agency for Healthcare Research and Quality, “Mistaken Identity.” ECRI Institute, “Patient Identification Errors.” JAMA Network, “Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era.” WebMD, “Thousands of Mistakes Made in Surgery Every Year.”

What do we know about the epidemiology of patient medication errors?

The epidemiology of patient medication errors (PEs) has been scarcely reviewed in spite of its impact on people, on therapeutic effectiveness and on incremental cost for the health systems.

How common are medical errors in hospitals?

According to data provided by the U.S. Department of Health and Human Services, one in seven patients on Medicare in a hospital setting is the victim of a medical error. A Johns Hopkins study released in 2016 estimated that roughly 250,000 people die annually because of medical errors.

What are the top 5 most common medical errors?

What Are the Top 5 Most Common Medical Errors?Misdiagnosis. Errors in diagnosis are one of the most common medical mistakes. ... Medication Errors. Medication errors are one of the most common mistakes that can occur during treatment. ... Infections. ... Falls. ... Being Sent Home Too Early.

What are some examples of medication errors?

The three most common dispensing errors are: dispensing an incorrect medication, dosage strength or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications. Errors caused by drug administration can be made by the health care provider or by the patient themselves.

What is the most common error in patient care?

Most Common Preventable Medical ErrorsMisdiagnosis. The wrong diagnosis can prove catastrophic to a patient in serious need of medical intervention. ... Medication Error. ... Faulty Medical Devices. ... Infection. ... Failure To Account For Surgical Equipment. ... Improper Medical Device Placement.

What is the most common cause of medication errors?

The most common causes of medication errors are:Poor communication between your doctors.Poor communication between you and your doctors.Drug names that sound alike and medications that look alike.Medical abbreviations.

How are medication errors reported?

Medication errors are detected by voluntary reporting, direct observation, and chart review. Organizations need to establish systems for prevention of medication errors through analyzing the cause of errors to identify opportunities for quality improvement and system changes (Morimoto, Seger, Hsieh, & Bates, 2004).

Are nurses responsible for medication errors?

Nurses have always played a major role in preventing medication errors. Research has shown that nurses are responsible for intercepting between 50% and 80% of potential medication errors before they reach the patient in the prescription, transcription and dispensing stages of the process.

Which is the most common cause of medical errors in the healthcare field?

Communication Problems Communication breakdowns are the most common causes of medical errors. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. Poor communication often results in medical errors.

What are the common medication errors encountered by nurses?

Seven common medication errors in nursing homes include:Providing patients with the wrong medications. ... Prescribing the wrong dosage. ... Ignoring patient medical histories. ... Providing medications that should not be taken together. ... Improperly administering medications. ... Failing to provide medication. ... Improper preparation.

How often do nurses make med errors?

While a great number of nurses (64.55%) reported medication errors, 31.37% of them reported to be on the verge of a medication error.

What are the most medication errors?

Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors.

What is medication error?

Introduction: Medication errors have been analyzed as a health professionals' responsibility (due to mistakes in prescription, preparation or dispensing). However, sometimes, patients themselves (or their caregivers) make mistakes in the administration of the medication. The epidemiology of patient medication errors (PEs) has been scarcely reviewed in spite of its impact on people, on therapeutic effectiveness and on incremental cost for the health systems.

What are the most common mistakes made by the elderly?

The most common were: incorrect dosage, forgetting, mixing up medications, failing to recall indications and taking out-of-date or inappropriately stored drugs. The majority of these mistakes have no negative consequences.

What can lead to medication errors?

Insufficient exchange of information and poor communication between the specialist and home-care health services, and between general practitioners and healthcare workers can lead to medication errors. A lack of competence in healthcare workers can also lead to medication errors.

Why is it important to have openness when medication errors occur?

It is also important to ensure adequate competence with regard to medication, and that there should be openness when medication errors occur, as well as in setting routines for the preparation, alteration and administration of medications.

Why is it important to ensure adequate competence with regard to medication?

It is also important to ensure adequate competence with regard to medication, and that there should be openness when …. To prevent medication errors in home care, up-to-date information and communication between healthcare workers is important when patients are transferred from specialist to home care. It is also important to ensure adequate ...

Can lack of competence lead to medication errors?

A lack of competence in healthcare workers can also lead to medication errors. To prevent these, it is important that there should be up-to-date information and communication between healthcare workers during the transfer of patients from specialist to home care. Ensuring competence among healthcare workers with regard to medication is also ...

What are Medication Errors?

The National Coordinating Council for Medication Error and Prevention (NCCMERP) has approved the following as its working definition of medication error: “... 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”.

How many people are affected by medication errors?

Medication errors are among the most common medical errors, harming at least 1.5 million people every year. The extra medical costs of treating drug-related injuries occurring in hospitals alone are at least to $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs, the report says. 1 Medication error morbidity and mortality costs are estimated to run $77 billion dollars per year. 2 Patient safety is a major public health concern. The Academy of Managed Care Pharmacy (AMCP) recognizes the importance of this issue and supports programs that help achieve the goal of improved patient safety and prevention of medication errors. AMCP’s Framework for Quality Drug Therapy, 3 emphasizes and promotes public safety, continuous monitoring for accuracy in dispensing, reliability in the transmission of prescription and medication orders, and continuous review and upgrade of pharmacy operating systems.

What are dispensing errors?

The term dispensing error refers to medication errors linked to the pharmacy or to whatever health care professional dispenses the medication. These include errors of commission (e.g. dispensing the wrong drug, wrong dose or an incorrect entry into the computer system) and those of omission (e.g. failure to counsel the patient, screen for interactions or ambiguous language on a label). Errors may be potential -- detected and corrected prior to the administration of the medication to the patient. 6 The three most common dispensing errors are: dispensing an incorrect medication, dosage strength or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications.

Why are preventable errors occurring?

Preventable errors occur because systems for safely prescribing and ordering medication are not appropriately used.

How does e-prescribing work?

E-prescribing Utilization of electronic prescribing by entering orders on a computer, better known as Computerized Physician Order Entry (CPOE), is a technology that could help prevent many medication errors. CPOE systems allow physicians to enter prescription orders into a computer or other device directly, thus eliminating or significantly reducing the need for handwritten orders. E-prescribing and CPOE can reduce medication errors by eliminating illegible and poorly handwritten prescriptions, ensuring proper terminology and abbreviations, and preventing ambiguous orders and omitted information. 13 More advanced CPOE software incorporates additional safety features that allow the physician to have access to accurate patient information, including patient demographic information such as age, medication history and medication allergies.

How can electronic technology improve patient safety and reduce medication errors?

One way in which electronic technology can improve patient safety and reduce medication errors is through the use of standard machine-readable codes ("bar codes"). Medication bar coding is a tool that can help ensure that the right medication and the right dose are administered to the right patient.

What are the causes of errors in prescribing?

Errors in prescribing can occur when an incorrect drug or dose is selected, or when a regimen is too complex.

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When it comes to medicine, "more is not always better"?

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How many states have "I'm sorry" laws?

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Do doctors report medication errors during surgery?

But a new study out of Massachusetts General Hospital, based on researcher observations during 277 procedures in the anesthesiology department, arrived at a far different conclusion: that about half of all surgeries involve a medication error or "adverse" drug...

What is medication error?

A medication error is any error occurring in the medication use process, including during prescribing, transcribing, dispensing, administration, adherence, and/or monitoring (2, 3). Medication error may not always result in injury and therefore will not always be an ADE. ADEs may be preventable or non-preventable.

Which is the third most common source of medication errors?

The emergency department is the third most common source of medication errors (14) (P).

What is the name of the drug that was given to a 71 year old woman?

A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms.

What medications did the med REC report?

Admission medication reconciliation (MED REC) revealed that she was taking metoprolol, doxazosin, alprazolam, citalopram, and thiothixene (Navane) 10 mg twice daily.

Why is medication reconciliation important?

Medication reconciliation including an ‘indication review’ for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider–patient relationship.

How many people will have more than one chronic condition in 2020?

It is projected that by the year 2020, 157 million Americans will have more than one chronic condition (11). Patients with chronic conditions may see as many as 16 physicians annually; this creates a huge potential for ADEs, poor communication, and fall out (12). A recent article published in the British Medical Journaldescribed medical error as the third leading cause of death. Their data analysis included greater than 400,000 deaths a year from medical error, none of which captured deaths outside inpatient care due to lack of ICD 10 coding. One of their foundations for improvement called for increased error awareness and the ability to discuss errors (13).

Why is MED REC important?

A thorough MED REC and review of indications is an important aspect of patient safety. Pharmacy department, outpatient providers, hospitalists, and specialists should be reviewing medications and their respective indications, and providing education to patients. Office and hospital medication reconciliation should be ultimately done by the prescriber, without being solely delegated to ancillary staff. The development of unusual symptoms or poor treatment response should trigger an evaluation by the physician and/or pharmacist along with a pill bottle review.

What hospital in Oregon administered the wrong medication?

Hospital medication error kills patient in Oregon. A hospital in Bend, Oregon, says it administered the wrong medication to a patient, causing her death. Loretta Macpherson, 65, died shortly after she was given a paralyzing agent typically used during surgeries instead of an anti-seizure medication, said Dr.

What is the investigation of medication?

The investigation is looking at every step of the medication process: from how the medication was ordered from the manufacturer, to how the pharmacy mixed, packaged and labeled the drug, to how it was brought to the nurses and administered to the patient.

What medication did Macpherson take?

According to the Bend Bulletin, the doctors determined Macpherson needed an intravenous anti-seizure medication called fosphenytoin, but instead accidentally administered rocuronium, which caused Macpherson to stop breathing and go into cardiac arrest, leading to irreversible brain damage.

What happened to Macpherson?

He said Macpherson stopped breathing and suffered cardiac arrest and brain damage.

Did Boileau say there was a medication error?

"We are in the process of that analysis right now. Before we say exactly what happened, we're going to make sure we're accurate about. We do know there was a medication error. We acknowledge that. It's our mistake."

How many medical bills contain errors?

As many as 80 percent of medical bills contain at least one error.

What Causes Medical Errors?

What are the factors that go into creating a medical error, and are they fixable? Can we reduce the number of medical errors, and more importantly, the adverse effects of these errors on patients?

Why are there errors in the workplace?

In some cases, errors are caused by new staff, who are still learning or haven’t encountered a specific situation before, and therefore haven’t had the necessary training to know how to handle the issue presented.

How many people die from medical errors in a year?

Some studies indicate that death from medical errors could be even higher due to the way medical errors are reported on death certificates—with as many as 440,000 people dying every year from medical errors. The number of deaths caused by medical errors is far too high.

Why do billing errors occur?

Billing errors happen when patients are charged for procedures they did not receive, or are charged for staying longer at an in-patient facility than they actually did, or correct procedures/stays have been coded incorrectly due to data entry errors.

What does it mean to tell a patient to take the wrong medication?

Telling the patient to take the prescription at the wrong time of day. Giving the improper dose of medication. Failing to check whether the patient is allergic to that medication. Failing to check whether there are other medications the patient takes that could interact with the prescribed drug.

What happens if a new procedure is developed?

Finally, if a new procedure is developed for the treatment of a disease or illness, there is always a learning curve related to putting that new procedure successfully into practice. Sometimes a health care provider picks up the new procedure quickly; but if they don’t, medical errors may occur.

How did James River Convalescent and Rehabilitation Center die?

The suspicious death of a 76-year-old patient of the James River Convalescent and Rehabilitation Center in Newport News, Virginia has attracted the interest of police, who are investigating. Apparently, the patient died after he was reportedly given “unauthorized medication” by a nurse employed by the facility. Other employees of the facility may have made the complaints that launched the investigation. The medical examiner’s office was contacted to perform an autopsy, and police are waiting to receive the results of a toxicology test. Read more about the suspected medication error.

Why was Narcan administered to the hospital?

An ambulance was called, and ambulance attendants administered Narcan en route to the hospital to reverse the effects of the morphine overdose. When the patient arrived at the hospital, she remained unresponsive, had cardiac ischemia, non-cardiogenic pulmonary edema, and her condition was serious.

Why do medical errors occur?

Manges says that most medical errors occur because of systemic problems. Human error is inevitable, she says, and hospitals should account for that by instituting safety checks and protocols.

How common are medical errors?

Medical errors are common. Some researchers estimate they're the third leading cause of death in the United States. And many in the patient safety community say they don't understand what prompted the DA's office to prosecute this case in particular.

What was the name of the nurse who was arrested for a medical error?

Vaught, a former nurse at Vanderbilt University Medical Center, was charged with reckless homicide after a medication error killed a patient. A former nurse at Vanderbilt University Medical Center in Nashville, Tenn., was arrested and charged with reckless homicide and abuse in February for making a medical mistake that resulted in an elderly ...

What is the American Nurses Association's statement criticizing the charges?

The American Nurses Association issued a statement criticizing the charges, saying that "the criminalization of medical errors could have a chilling effect" on health care workers' willingness to report errors.

What are the most high profile cases?

Most high-profile cases tend to involve death, a significant injury or a patient well-known in the community, he says. And prosecutors tend to focus on nurses, he says, rather than physicians or hospital administrators, though he's not sure why.

Why should health care mistakes be analyzed?

All health care mistakes — even small ones — should be analyzed to understand the underlying issues that caused them , Ross says. A non-punitive approach encourages transparency, she says, and "that prevents future mistakes or errors from happening.".

When did the Institute of Medicine publish the report "To Err Is Human"?

When the Institute of Medicine — now known as the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine — put out a major 1999 report titled To Err Is Human, Manges says, it became the norm to focus less on punishment and more on learning from mistakes.