Introduction to Medication Errors

Happening this week: Chiang will first explore medication errors, different aspects of safety in this activity before moving onto ethics in a later activity.

Chiang first gives a background to how the world views medication safety issues, before moving on to explain some essential terminology.

Medication Error Key Points

An IOM report, published in 2000 is titled: To Error is Human: building a safer health system. It discusses the inevitability of human errors and the possible efforts to prevent them. It also highlighted the pervasive nature of injuries associated with medication use, concluding that medical errors are chronic threat to public health.

Terminology

• Drug-related problems, drug therapy-associated events that hamper optimal patient health outcomes. Includes medication errors, adverse drug reactions, adverse drug events, and side effects.
• Medication misadventures, iatrogenic hazards, or incidents that can be attributable to error, immunologic response, or idiosyncratic response. Similar to drug-related problems, the terms are quite interchangeable.
• Medication errors, errors, or mistakes in the medication use process (prescribing, transcribing, dispensing, administration, or monitoring). Can be categorised based on the severity of impact or by medication process. Medication errors with no negative health outcomes are further classified into latent and potential injuries.
• Adverse drug reactions (ADR), unexpected and unintended responses to a drug that require a medical response. It may or may not be the result of a medication error.
• Side effects, expected or well-known reactions. Don’t require patient management.
• Adverse drug events, ADRs that result in injury or severe side effects that require extensive medication management.
• Drug-related morbidity, event where drugs fail to achieve the intended health outcome due to unresolved drug-related problems.
• Sentinel events, unexpected incidents resulting in death, or the potential for serious physical or psychological injury.
• Errors of commission, errors occurred when the patient receives a drug.
• Errors of omission, error occurred when the drug did not enter the patient’s system.

To learn more about medication errors, check out this course: “Good Pharmacy Practice: Pharmaceutical Services from Taipei Medical University.