return to: Maximum Recommended Doses and Duration of Local Anesthetics
Created July 2018: Vivian Zhu
Modified September 2018: Dr. Henry Hoffman, Vivian Zhu
Medications are ubiquitous in the healthcare world. Given the prevalence of medication use among patients, the array of pharmacologic agents to choose from, and the complex and evolving nature of medical care, medication errors continue to be a significant issue in patient safety. There are many variations on the definition of a medical error in the literature most centering on scenarios where a mistake is made with a medication that leads to, or has the potential for, patient harm.
The exact incidence of medication errors is difficult to identify, as is the proportion of errors that actually lead to serious consequences for patients. Error rates can vary widely between studies depending on health care setting, types of drugs being studied, the clinical scenario, and individual study definitions of an "error" worth noting. For example, one US study found 1.7% of prescriptions from community pharmacies had errors (Flynn et al 2003), while another looked at inpatient prescriptions and found error rates of 5.3% (Bates et al 1995). Additionally, physicians are thought to underreport errors due to fear of disciplinary or litigious consequences, and patients often do not know enough about their medical conditions and their medications to recognize when a mistake has been made. Regardless of the numbers, medication errors can be a serious problem in patient care, and should be at the forefront of any healthcare provider's mind during clinical work.
Opportunities for Errors
There are many moving parts involved in bringing a drug from creation to the patient. At any point in this process, errors can occur. Some of these errors may, in isolation, directly impact a patient. More often, errors are caught and neutralized by various defenses in the system. Examples of these include pharmaceutical quality control, a team approach to patient care, surgical time-outs, physical checkpoints to medication administration, etc. However, these defenses each have their own "holes" of fallibility. If the right number and combination of "holes" align to allow an error-in-the-making through, patients end up harmed by our mistakes. This phenomenon of human error is known as the Swiss cheese model of system accidents, and results from both humans themselves as well as from pathology within the system. Actions by people are known as "active failures," while systemic issues that predispose people to making an error are known as "latent factors." In our role as patient care providers, we have an obligation to minimize our own active failures, at every possible step in the process.
Types of Active Failures & Preventative Strategies
The following chart (adapted from text Aronson 2009 and Zakharov et al 2012) illustrates four broad categories that active failures may fall into. Categories are not mutually exclusive; while some mistaken actions may be a simple, one-step occurrence, many occur in complex care situations and stem from multiple factors.
Error Type |
Description |
Example(s) |
Prevention |
|---|---|---|---|
|
Knowledge |
Lack of awareness or education about the patient and/or the specific clinical situation |
|
|
|
Memory |
Lapses in recall and/or attention despite prior knowledge |
|
|
|
Rule-based |
Inappropriate rules or misapplication of good rules |
|
|
|
Action-based |
The action of obtaining and/or administering the medication itself is in error, or technical mistakes in administration |
|
|
While the above categories focus on the provider as an individual source of a mistake, latent factors should also be taken into account when thinking about quality improvement measures. Examples of latent factors include overtime hour policies, inadequate resources and staffing, worker depression or burnout, working mostly with unfamiliar patients, and differences in prescription and electronic medical record systems across various hospitals and cities.
9 Questions to Ask Before Prescribing (Aronson 2009):
- Indication: Is there an indication for the drug?
- Effectiveness: Is the medication effective for the condition?
- Diseases: Are there important comorbidities that could affect the response to the drug?
- Other similar drugs: Is the patient already taking another drug with the same action?
- Interactions: Are there clinically important drug-drug interactions with other drugs that the patient is taking?
- Dosage: What is the correct dosage regimen (dose, frequency, route, formulation)?
- Orders: What are the correct directions for giving the drug and are they practical?
- Period: What is the appropriate duration of therapy?
- Economics: Is the drug cost-effective?
References
Aronson JK. Medication errors: what they are, how they happen, and how to avoid them. Q J Med 2009;102:513-521.
Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10(4):199-205.
Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc 2003;43:191-200.
Reason J. Human error: models and management. BMJ 2000;320:768-70.
Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo Clin Proc. 2014;89(8):1116-1125.
Zakharov S, Tomas N, Pelclova D. Medication errors - an enduring problem for children and elderly patients. Upsala Journal of Medical Sciences 2012;117:309-317.