Mistakes in the medications patients take are in many ways a hidden patient safety problem. Data about medication errors can vary on the sources of the problem. But the key takeaways are universal:
- Each year, between six and ten thousand Americans die because of medication errors.
- Hundreds of thousands of people report suspected medication errors to the U.S. Food and Drug Administration every year.
- Thousands of other patients experience but do not report an adverse reaction or other medication complications.
- The total cost of looking after patients with medication-associated errors is billions of dollars annually.
Unfortunately, medication errors have become too commonplace. What makes this fact even more unfortunate is that medication errors are avoidable with the right processes, policies, people, and technology in place.
Medication Errors: Reasons Why They Happen
In this post, we'll look at some of the most common cause of medication errors. Use this information to take a closer look at how your organization performs medication management and what opportunities exist for you to decrease medication errors. As we previously stated, "Organizations should set a goal of zero medication errors and adverse drug events, including those associated with modifying patient regimens. While achieving this goal may seem unrealistic, any goal other than zero would suggest a willingness to accept some medication errors."
1. Suboptimal medication reconciliation workflow
We'll begin with this common cause because it's one of the most significant but also one of the most overlooked. Poor medication reconciliation workflow is a subject we previously wrote about, noting, "When med rec is not performed properly, consistently, and at its highest level of effectiveness, errors and oversights are more likely to occur."
One of our top recommendations on how to improve med rec workflow: putting pharmacists in charge of medication reconciliation. "Letting pharmacy lead could be the missing link to decreasing the medication errors and adverse drug events your organization has been striving toward."
2. Lack of medication reconciliation post-discharge (MRP)
We follow suboptimal med rec workflow with this common cause because the two are intertwined. That workflow must include medication reconciliation post-discharge. The problem: As we note here, MRP is not performed on many discharged patients. Statistics indicate that up to half of all patients never receive an MRP.
Why is this so concerning? As Cureatr Chief Executive Officer Richard Resnick stated, MRP is vital because "the discharge from the hospital to the home is one of the most dangerous care transitions for all patients, but particularly for those with complex medication regimens."
3. LASA medications
Look-alike sound-alike (LASA) medications are regularly cited as one of the top causes of medication errors. In fact, a list of confused drug names from the Institute for Safe Medication Practices spans nine pages. ISMP also maintains a list of error-prone abbreviations, symbols, and dose designations. As ISMP notes, "These abbreviations, symbols, and dose designations should never be used when communicating medical information."
An AmBuzz blog post from The Joint Commission highlights the challenges of LASA medications and risks associated with "high-alert/hazardous" medications. The author concludes, "We want to provide a zero-harm experience with medication administration, and it is critical all staff are aware of the risks with high-alert/hazardous and LASA medications."
4. Poor communication during transitions
The process of passing patient-specific information from one clinician to another is a crucial step for ensuring patient safety. But when handoffs/handovers are rushed, incomplete information is shared, clinicians are distracted, there's a lack of standardized procedures, or any number of other issues, the likelihood of a medication error increases greatly. That's one of the reasons why best practice is to have medication reconciliation performed at each patient encounter.
5. Poor communication between clinicians and patients
In a similar vein, poor communication between clinicians and their patients also increases the possibility of medication errors. Communication issues can arise due to a host of issues, including a rushed encounter, distracted clinician or patient, a greater focus on "checking the box" than careful and proper completion of processes, and language and cultural barriers.
Suboptimal communication about medications is likely to contribute to inaccurate documentation concerning the medications a patient is taking and their details (e.g., dosage, frequency, route) as well as any preexisting conditions and allergies that should be understood when prescription decisions are made. If information is documented incorrectly, decisions made using this information are more likely to put a patient's health and wellness in jeopardy.
6. The emergency department
It might seem strange to cite a specific department as a cause for medication errors, but it's important to acknowledge that the emergency department (ED) as a location where the likelihood of a medication error increases. Consider that a frequently cited Open Access Emergency Medicine report states, "The ED experiences a high frequency of medication errors, with estimates of medication-error rates varying from 4% to 14% to as high as 39% in pediatric ED settings."
Factors contributing to such a high rate of medication errors include the following:
- High patient volume
- Unpredictable surges in patient volume
- Difficult patients
- Patients arriving unprepared or unable to share important medication and health information
- Overwhelmed staff
- High rotating staff
- Staffing shortage
Another factor that we highlighted in this blog post about medication reconciliation in the emergency department: "Most EDs lack the right people with the right training performing medication reconciliation and doing so correctly at the right time. In most hospitals, ED personnel who end up being tasked with med rec are not well-versed enough in the medications they are discussing with patients, especially more complex and challenging patients. Unfortunately, the resulting medication errors can be disseminated throughout the hospitalization and potentially well beyond discharge."
Making Medication Errors a “Never Event”
Never events in medicine are errors in care that are clearly identifiable, preventable and serious in their consequences. While it may not be possible today to eliminate all medication errors, it is possible to take steps that will make medication errors a truly rare and atypical occurrence. At Cureatr, we combine clinical pharmacy experts, advanced technology, and comprehensive data to "solve the medication management puzzle." Learn about the range of solutions that we serve to providers, patients, and payors, and schedule a demo to find out more.