Preventable Medication Errors

The National Academy of Science’s Institute of Medicine estimates that preventable medication errors cost hospitals and extended care facilities over $5 billion annually, and account in over 7000 hospital deaths.

The majority of these medication errors occur in the ordering and administration stage. It is crucial that health care professionals take extra care in ordering and handling medications.

For example, the Institute for Safe Medication Practices (ISMP) has issued warnings about potential confusion over the following drugs: Lantus and Lente insulin both diabetes drugs; the antidepressant Serzone and the antipsychotic Seroquel, and the oral diabetes drug Avandia and the anticoagulant Coumadin.

Over a dozen mistakes have been reported involving Seroquel and Serzone. The names are very similar. Mistakes involving Lantus and Lente insulin have also been reported.

In 1991 the Institute of Medicine called for the elimination of paper-based record keeping. Since that time a computerized physician order entry (CPOE) system has been developed. The real goal in implementing this type of system is to reduce medication errors. This system checks for potential drug interactions, appropriateness of drug and the dosage ordered, and it integrates the ordering system with the pharmacy, laboratory’s and the nurses station.

Hopefully in future all hospitals will have the ability to implement this new system, and the lives and money saved will be immense. Until then it is vital that every health care professional involved in prescribing, preparing, and/or administering medications of any kind to compare the exact spelling and concentration of the medication ordered with the patient’s medication card, and read the label three times before the drug is removed from the shelf or unit dose cart, before preparation, and before opening the drug for administration.

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