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1.3 million people have injuries that result from medication errors annually in the United States. A study recently published in Pediatrics found that one American child was given the wrong medication every eight minutes, although many of these errors were caregiver errors. A definition of 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 healthcare professional, patient, or consumer.
Medications that are associated more commonly with death or severe adverse drug events are those medications that involve the central nervous system, the cardiovascular system, or cancer chemotherapy drugs.
The black box warning system that was established by the FDA in 1995 alerts doctors to the increased risks that are associated with some drugs.
In my own family, my father was discharged from the hospital with a prescription for a medication that would have caused a fatal drug interaction with another medication he had been taking for a long time.
Anyone who begins a new prescription should understand the drug and its effects, and any interactions with other medications they are taking. Prescription drug abuse is an epidemic in the United States, and sometimes a physician may be negligent by prescribing a dangerous drug to a patient at risk. One problem arises when a doctor prescribes a narcotic to a patient who may be dependent upon narcotics or may be abusing them. Overdose death drugs rise yearly, and in 2010, 38,329 people died of drug doses in this country, according to the US Center for Disease Control’s National Center for Health Statistics.
Prescription drug overdoses are usually unintentional, with 74% of prescription drug overdoses resulting from accidental ingestion. Although hospitals and pharmacies have tightened restrictions on prescribing, it is still relatively simple for many people to obtain a large supply of painkillers or anti-anxiety drugs like Xanax or Ativan.
Although the FDA requires the manufacturers of opioid drugs, like Vicodin or Oxycontin, to provide education for doctors, their track record is poor. Plaintiffs have been successful in lawsuits against physicians who have prescribed dangerous drugs irresponsibly. Doctors who are specialists in pain management should be especially careful, as they are often responsible for the prescription of powerful and addictive drugs over an extended period of time. If you or a family member has suffered as a result of negligent prescribing practices by your doctor, you may have legal recourse.
Many nursing homes under-employ staff with the experience and ability to administer medications correctly.
If your loved one in a nursing home has suffered a serious injury or death as a result of neglect or outright reckless conduct, call Passen Law Group at 312-527-4500. Among the most common drugs involved in medication errors are blood thinners and antihypoglycemic medications prescribed for diabetes. A recent study  found that warfarin (Coumadin), oral anti-platelet medications (Plavix, aspirin), insulin and medications like metformin or glipizide. Sometimes equipment malfunctions, and large doses of drugs that should be administered over a long time period are delivered too rapidly. Morphine and other uploads are stacked together in a locked cabinet, with similar packaging, contributing to errors. Acetaminophen causes multiple problems, due to its various strengths and measuring devises for dispensing it.
With antibiotics, liquid concentrations cause confusion, especially over the measurement m: and the teaspoon.
System errors include inadequate staffing, handwritten orders, and doses with trailing zeros or ambiguous labeling.
If you or a loved one has been the victim of a medication error, you should see an attorney who specializes in medical malpractice. Another recent peer-reviewed study by Accredo Health Group and several university hospitals highlights how the wrong medication and other administration errors can be life-threatening. To speak with a top Chicago medical malpractice lawyer, call Passen Law Group at (312) 527-4500 for a free consultation.
We often note here that quality improvement in hospitals seems excruciatingly slow to happen, and engaged patients and families need to keep their eyes wide open, because sometimes a fix doesn’t require being a genius.
We’re in our 13th year after To Err, yet this morning SPM member Paul Bearman spotted this article by Maura Lerner in the Minneapolis Star Tribune and posted a note on our member listserv.
What I love about the story is how intelligent change can be so wonderfully effective.   A small tweak reversed critical failures in discharge prescribing.
He and his colleagues decided to do a spot-check of 37 patients who were discharged from the hospital to nursing homes over three months in 2008 and 2009.
The most common problems: Hospital physicians had prescribed the wrong doses, duplicate medications or omitted medications.
The project worked so well, Thompson said, that some doctors now call the pharmacist before they write the discharge orders. Share the Star Tribune article with your hospital (and nursing home’s) pharmacy staff. I personally know of two cases in my own family, in the past year, where medications were overlooked or wrong at discharge. Kudos to Bruce Thompson and team at Hennepin County Medical Center – and to all the people there who gladly adopted the change.
The doctor’s original thought is still, in a way, being inspected by the pharmacist before the order is being written. I hope that the pharmacists aren’t continually finding and fixing the same problems, whether before or after order writing.
That pharmacist inspection step is going to be prone to failure, before or after order writing, since 100% human inspection is never 100% effective.
I appreciate the efforts being made in hospitals, but what about the walking wounded in the clinics. Participatory Medicine is a model of cooperative health care that seeks to achieve active involvement by patients, professionals, caregivers, and others across the continuum of care on all issues related to an individual's health.
An example of a medication error caused by misread prescription written by physician caring for diabetes patient.
One research study revealed that the amount of medication errors and medicine mistakes involving doctor’s bad handwriting was a shocking 37 errors for 100 prescriptions (37%).

Medication errors are so commonplace among medical professionals that these medicine mistakes have a nickname: they’re called an “ADE” (for “Adverse Drug Event”).
Consider a case out of Texas this week, where the poor penmanship of a doctor was so impossible to read by anyone else that a patient was killed by a fatal medication error, as a kidney dialysis patient hospitalized for amputation of a toe was given 120 millimoles of potassium instead of the prescribed 20 millamoles. At trial, the doctor explained that he had decided to up the dosage from 10 to 20, and used his pen to change the “1” to a “2.” Seems like an easy enough thing to do, right? Except it was read not as “10” or as “20” but as “120” — and as a result, the 72 year old woman died from an overdose of potassium. The jury found for the family and against the doctor this week in a jury trial; the hospital has already settled with the patient’s family. Long ago, whether or not a doctor had bad handwriting was not such a big deal, because they were always around to answer questions and oversee things. These preventable ADEs are shameful, and rarely are they going to be freely acknowledged by the health care providers to the patient or their family.
A good piece of advice if you or a loved one has been harmed because of a medical provider’s error, is to at least speak with an experienced personal injury lawyer before you file a claim to learn about some of the issues that can arise with these claims, including the type of evidence needed to prove a claim and the type and amount of damages you can recover. If you found this information helpful, please share this article and bookmark it for your future reference.
To learn about the 5 things you get when you hire Alan Sackrin, click on the "About" link above. How Do You Know If A Business Acted Reasonably In Trying To Prevent an Office Slip and Fall Accident? How Do You Know If A Business Acted Reasonably In Trying To Prevent a Restroom Slip and Fall Accident? The hiring of a lawyer is an important decision that should not be based solely upon advertisements. Before you decide, ask us to send you free written information about our qualifications and experience. Anywhere RN™ creates a flexible medication administration process that positively impacts nursing and patient safety. The latest release of Anywhere RN software features enhanced privacy for patient data and more configurable options to improve patient safety and assist in meeting regulatory requirements.
Crowding at the ADCs takes valuable time away from nurses and also limits access for pharmacy. By reducing the number of trips to and from the ADC, Anywhere RN helps reduce the potential for interruptions that can lead to medication errors in nursing, and it frees up more time for patient care. Fewer lines at the cabinet during the medication pass process increases nurse satisfaction. When used with Omnicell's Savvy™ mobile medication workstation, nurses can securely retrieve medications for multiple patients in one trip to the cabinet.
Objectives (cont.) Compare the preferred sites for intramuscular injection for infants and adults. 11-week programs focuses on education, support and coping strategies for family and friends.
Annapolis Valley Health offers an extensive listing of programs and services to help you be healthy and stay healthy. Visit our tri-district website featuring Changing our Picture of Health a series of videos and tools to help you understand (or facilitate) the social determinants of health. Reduction of medication errors requires constant attention as inaccuracies can lead to serious and life threatening effects on patients.
The Institute for Safe Medication Practices (ISMP) in Canada has compiled a list of abbreviations, symbols, etc.
Provide education for health care professionals about abbreviations that should be avoided in practice. Review and revise all preprinted orders and clinical pathways to ensure that no dangerous abbreviations are present. Provide examples of errors that have resulted from the use of dangerous abbreviations during orientation for all new staff.
Drugs may have similar names and the order or prescription may be written wrong, written illegibly, or incorrectly transcribed. The most common error is improper dosing of a medication, and in 1998, the FDA found that dosing errors caused 41% of fatalities resulting from medication errors. Every patient who receives a prescription for a medication is potentially at harm, despite the many benefits of effective medication management. If your doctor has wrongly prescribed a medication or if you were a hospital patient who received the wrong dose or wrong medication with serious consequences, you should consult a Chicago malpractice attorney at Passen Law Group for a review of your records. There have been a number of lawsuits in the news as a result of alleged medical negligence in prescribing. Some doctors refer to these patients as “frequent fliers.” At one time, emergency departments would keep a card file with these patients, but that practice has been outlawed. Many overdoses occur in people who are treated by their doctors with a combination of narcotics and sedatives. In the past, knowing the risks of addiction and overdose, pharmaceutical representatives continued to encourage physicians to over-prescribe. An Alabama widower won $500,000 in a lawsuit after his wife died of an overdose from narcotics and sedative-hypnotic drugs. These physicians should be especially careful by screening their patients for drug abuse or addiction, and they should sign a pain contract, which allows them to terminate care if patients obtain narcotics from another physician.
Sometimes these errors are not only due to lack of qualified staff but to failure to train and supervise employees. The 2006 study described harmful medication errors as 1.5 million incidences ranging from the prescription to administration. Additionally, interactions are not checked when new medications are prescribed and this can even be fatal in some instances, particularly with cardiac medications. Medications errors may be due to negligence and it is important to call attention to these systemic problems. It’s a great example of the positive impact pharmacists can make when positioned properly in the healthcare system.

From my own experiences in a large HMO, I finding about 50% errors, and thanks to the pharmacist that caught the last one. Participatory medicine is an ethical approach to care that also holds promise to improve outcomes, reduce medical errors, increase patient satisfaction and improve the cost of care.
Science Daily reports that this number may be much higher, with as much as 61% of the medication errors taking place in hospitals being the result of a physician’s handwriting that is simply too hard to read correctly, or from a transcription error when someone tried to decipher what the doctor had written. When these ADEs cause serious injury or death all because someone’s handwriting isn’t legible, then it’s a real injustice since these are obviously preventable events.
The doctor argued that this was not all his fault, because 120 millimoles of potassium is so over the range of acceptable dosages for a human that anyone on the hospital staff — any nurse, any lab tech, any doctor or nurse practitioner – would know (or should have known) that 120 was the wrong number.
In today’s modern medical environment, doctors aren’t always hands-on with their patients, especially during their hospital stay. If you or a loved one suspect that they have been a victim of an ADE or medication error, then you may need professional investigation and legal assistance to discover the truth and get justice. Most personal injury lawyers, like Alan Sackrin, will offer a free initial consultation (over the phone or in person) to answer your questions.
It is a web-based application that lets nurses remotely perform medication management tasks away from the automated dispensing cabinet (ADC). Nurses often feel rushed if others are waiting in line, which causes stress and can increase the potential for medication errors. Nurse interrupted: South Jersey Hospital uses technology to reduce disruptions, avoid errors. Discuss two nursing responsibilities necessary when a child is receiving parenteral fluids and the rationale for each.
Data collection is done to determine the level of wellness, the response to medication or treatment, or the need for referral.
In many cases the use of abbreviations, symbols, and unclear dose designations as well as illegible handwriting, results in serious consequences. This study, published by the Institute of Medicine, titled To Err Is Human: Building a Safer Health System, found that medication errors accounted for more than 7,000 annual deaths at that time.
In nearly half the cases in one study, patients taking a medication with a black box warning were not monitored appropriately. A list of drugs with a black box warning or post-market safety concerns can be found on the FDA Drug Safety website. Another family member was given the incorrect instructions for Coumadin, or warfarin, and ended up taking 10x the dose, putting him at high risk for an intracranial hemorrhage. Today, most states keep detailed prescribing records of scheduled drugs, and in some states, before writing a narcotic, a physician is obligated to check the state database to determine if the patient has been “doctor-shopping,” or visiting a number of physicians to acquire a steady supply of narcotic drugs. In its place, however, there is a computerized registry that can be easily accessed by physicians to determine with some likelihood if a patient is abusing his or her prescriptions.
Many heroin addicts, who are by and large a young population, get their start with prescription drug experimentation, often stealing drugs from their parents or grandparents. A nurse in Mississippi died of an overdose in the hospital when her doctor prescribed one opiate when she was already under the influence of another powerful opiate. However, after signing such a contract, they should also check the state registry to be certain the patient is compliant. There should be protocols and guidelines for facilities in which these drugs are utilized, and failure to follow created protocols is malpractice. Doctors may right the wrong medication, or may fail to look up interaction with other drugs.
Much of the health care given to patients today is by non-physicians, who have been delegated the task of one-on-one care of the patient. Medicine mistakes and drug errors are seriously harming people and medication errors are killing patients all over the country, but the health care industry isn’t going to help victims voluntarily. Level of interaction between child and environment –Is child’s behavior withdrawn, normal for age and development, or inappropriate?
The ISMP recommends that these be eliminated from all documentation in the medication use process. An adverse drug reaction is any response to a drug that occurs at a dose normally used for therapy that results in a noxious effect that is not the result of medication error. This happens more frequently than the general public might imagine, and, because physicians are vested with the power to prescribe powerful drugs, they have the responsibility to prescribe cautiously and responsibly. Many older people in the country complain of chronic pain disorders, and, rather than prescribing physical therapy, non-narcotic analgesics, or topical treatments, doctors today tend to write prescriptions for narcotics. Since doctors are dependent upon these surveys for employment, they are frequently afraid to deny narcotics to patients who may be drug abusers or addicts.
More importantly, without adequate dissemination it can be difficult for other institutions to benefit from the practices reported here and ultimately to generate improvements for patients.
Doctors and hospital pharmacists may fail to check drug interactions, resulting in serious side effects or even death. This trend is a real change, as narcotics were primarily limited in the past to patients suffering from cancer pain.
At the same time, doctors don’t want to deny pain medications to patients who may legitimately be suffering. Demonstrate techniques of administering oral, eye, and ear medications to infants and children.
Doctors may ignore or overlook compromised kidney or liver function, failing to reduce doses or discontinue harmful drugs. When a dose is calculated by a doctor or nurse to be given IV, the drug dose may be off by a factor of ten or more, simply by misplacing a decimal point.

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