Prescription for Death: Medication Errors in the US

“To err is human, to forgive, divine.” – Alexander Pope

Picking up a prescription from a pharmacy in the United States is a relatively straight forward procedure. Your physician writes a prescription which makes its way to the pharmacy by one of a few methods (via the phone, an electronic method, or physical paper prescription drop off), where the pharmacist fills the prescription for the patient to pick up and pay for. However, as is possible with all systems, errors can and do happen. These errors can be relatively minor or they can be a matter of life and death. Perhaps a patient is given a generic drug rather than the brand name, or the dosage is not quite right. Sometimes an entirely different medication is given to a patient. Recent studies indicate that for children under the age of six alone, 63,000 medication errors occur annually in the United States.

When an error by a pharmacy is more serious, these issues often make the evening news. Anecdotal stories of dosages meant for adults that are given to small children, patients given medication meant for cardiovascular emergencies rather than an innocuous vitamin, and sadly, stories of patients dying from medication mix-ups in patients both young and old. In fact, these mistakes are common enough that there are law firms with attorneys that specialize in medication errors.

The Food and Drug Administration’s Division of Medication Error Prevention and Analysis (DMEPA) reviews medication error reports on marketed human drugs including prescription drugs, generic drugs, and over-the-counter drugs. The DMEPA uses the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) definition of a medication error, finding that 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.” In 2009 the agency released a consumer update to help educate the public on medication errors. In 2012 the FDA released a draft guidance  regarding safety considerations for products in order to reduce medication errors overall.

Consumers can report medication errors in a variety of ways:

Susan Paparella, MSN, RN, and vice president of the Institute for Safe Medication Practices has advocated that institutions move beyond voluntary reporting for medication errors, stating “Reporting yields important qualitative information, but it should serve as a stepping stone from which institutions can ask more questions, gather more useful information and perform more thorough risk assessments.”

Graduates from MIT have also recently invented a bedside pill scanner for hospitals, MedEye, a device that uses computer vision to verify hospital patients are being given the correct medications. The invention gives hope that technology can be used to assist pharmacies and health care providers from making medication errors. Pilot tests of the device have caught and prevented series medication errors and the makers of the device are in discussion with hospitals in the US for its use.




Happy Holidays from Wolters Kluwer

All of us at Wolters Kluwer wish you a safe and happy holiday season. We will resume our regular posting schedule on Friday, December 26th.

Happy Holiday

The health team at Wolters Kluwer is out of the office for the Thanksgiving holiday. We will resume our regular posting schedule on Monday, December 1st. In the interim we invite you to check out the Food and Drug Administration’s page on food safety for a healthy holiday.

Kusserow on Compliance: Technical Difficulties & What You Missed

The editorial team at Wolters Kluwer would like to apologize for a recent technical glitch that prevented the Kusserow on Compliance Newsletter from being sent out to its subscribers. The popularity of the content proved too much for our system, and after some adjustments and additions, we’d like to let you know we are back up and running. We’ve also listed all the posts written by Richard Kusserow during the newletter’s hiatus: