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The best way to understand how medication errors happen and how to prevent them is to consider their classification, which can be contextual, modal, or psychological. Psychologists consider an error to be a disorder of an intentional act, and they distinguish between errors in planning an act and errors in its execution. Knowledge-based errors can be related to any type of knowledge, general, specific, or expert.
Rule-based errors can further be categorized as (a) the misapplication of a good rule or the failure to apply a good rule; and (b) the application of a bad rule.
This classification can help understand how errors can be prevented, as discussed in detail elsewhere [15].
Medication errors, which can lead to adverse drug reactions, require clear and unambiguous definitions, so that patients, prescribers, manufacturers, and regulators can all understand each other. Statistics paint pictures that make remarkable claims, yet it’s very difficult to validate or construct exact data on the frequency and severity of errors.
Many of the errors are due to either people working tired, understaffing, junior staff not picking up on erroneous medication dosages, momentary lapses in judgment or failure to follow procedures (ie two staff checking drugs etc).
While errors like these happen from time to time, I’m not so sure they happen quite as frequently as people might assume.
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Models of human error can be helpful inA determining why errors have occurred in the past, where future vulnerabilities may lie, and how healthcare professionals might take action to make clinical practice safer.
We have mapped many of our learning resources to the RPS Faculty's Advanced Practice Framework and Foundation programme. Disclosing clinical trial data is a step in the right direction towards transparency, which benefits both the public and the pharmaceutical industry.
As a pharmacist working for an international charity, Owen Wood shares his knowledge ofA mass vaccination and medicines procurement.
Ingrid TorjesenCorresponding AuthorIngrid Torjesen is a freelance journalist specialising in health and health policy.


The actual costs of harm amount to around A?1.1bn per year, when the findings of published studies are brought together, the report says. Have your sayFor commenting, please login or register as a user and agree to our Community Guidelines.
Medication (the process) is the act of giving a medication (the object) to a patient for any of these purposes. Contextual classification deals with the specific time, place, medicines, and people involved. If a prior intention to reach a specified goal leads to action, and the action leads to the goal, all is well. The classification of medication errors on the basis of the underlying psychological mechanisms, based on how errors occur, can suggest strategies that help to reduce their occurrence. Often it comes up in a slightly sensationalised form in the media, with grim statistics accompanying a photo of a busy hospital, and comments made on the negative outcomes for recipients of such errors. For instance, according to The Australian, mistakes happen more frequently in Queensland than any other state or territory of Australia.
Certainly long periods of time go by without any errors being made, and most errors are fairly minor, with little or no consequences. Often times however the hospital or greater management disagree with front line staff as to who is responsible and why mistakes have occurred. She is a regular contributor to The BMJ and the Health Service Journal and is editor of The Advisor, a magazine for people working in smoking cessation services. This figure includes a calculation by the National Patient Safety Agency that hospital admissions for adverse drug reactions and harm related to medicine given during inpatient stays cost A?770m in 2007, and that A?5m was spent on litigation for drug-related medical errors between 1995 and 2007.
A medication (the object) can be considered to be the same as a medicinal product, which has been defined in terms of what a medicinal product is and what it does.
This definition reminds us of the distinction between the drug itself (the active component) and the whole product. However, it does not include medications when they are used to probe systems for nondiagnostic purposes, such as the use of phenylephrine to study baroreceptor reflexes in a physiological or pharmacological experiment.


Different definitions of medication errors have been tested, as all technical definitions should be. Multiplicity of medication safety terms, definitions and functional meanings: when is enough enough?
Errors in prescribing, preparing, and giving medicines – definition, classification, and prevention. Random and systematic medication errors in routine clinical practice: a multicentre study of infusions, using acetylcysteine as an example. Testing the practical aspects of therapeutics by objective structured clinical examination.
In the past she has acted as news editor for The BMJ; opinion, features and news editors for the HSJ and features editor for Nursing Times. It also incorporates a study that estimated better recognition of sepsis could save the NHS A?196m each year.
In this case it was done by devising scenarios and determining which would constitute an error under each of the definitions. Memory-based errors occur when something is forgotten; for example, giving penicillin, knowing the patient to be allergic, but forgetting. Staff posts include associate editor and news editor of GP newspaper, news editor of Pulse, and reporter at Australian Doctor, based in Sydney. However, classification based on psychological theory [21] is to be preferred, as it explains events rather than merely describing them.
Often, the full course of prescribed drugs is not taken because of a failure to monitor and properly encourage and instruct patients. Putting up posters that quantify the financial cost of safety incidents do not to my mind empower health professionals to make decisions about the resources available to them to make care safer.a€?What is needed is a cultural change, he says, a€?to allow an open and honest dialogue, encouraging learning from mistakesa€?.



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