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Images from the web about medication errors may be common after hospital discharge, hope you like them. Doctors’ poor handwriting may be an old joke, but the latest report from the United States Pharmacopeia (USP) shows that scrawl is no laughing matter. That represented 3 percent of the total number of medication errors reported voluntarily that year to the USP.
About 10 perfect of medication errors each year can be attributed to factors related to nursing shortages.
Physicians’ use of abbreviations in prescriptions caused another 7,400 medication errors in 2003. These trends are important, explains Diane Cousins, RPh, vice president of the USP’s Center for the Advancement of Patient Safety, because physicians often want to see evidence of a problem before they are willing to consider making a change in how they practice. These trends have been compiled and analyzed in the “Medmarx 5th Anniversary Data Report,” which was released in December. There were 24 patient deaths associated with a medication error reported to the USP in 2003. Just as importantly, the percentage of errors that were made but caught and fixed before they reached patients has jumped dramatically over the past five years. By focusing on near misses, she adds, health care organizations can design and reinforce existing safety nets—or create new ones.
Another interesting statistic: Over the years, the percentage of errors that can be tracked back to the prescription-writing process has jumped from 11 percent to 23 percent.
Despite those concerns, the number of facilities reporting medication errors to the USP over the last five years has skyrocketed from 54 to 580. And while she acknowledges that medication errors are still underreported, she says that the USP is “learning a lot from the records we are able to pull together each year for this study. Only about half of the time, in fact, do staff who made the error hear about the problem, and that type of notification—not any kind of broader system change—is the most common action taken after an error is found. Nonetheless, she says, there were more reports of hospitals instituting “systems changes” in 2003 than in previous years. For instance, patients and caregivers were informed of an error more often (5.5 percent) in 2003 than in the preceding years (4 percent).
Finally, the most common types of medication errors have remained steady over the last five years, with improper dose and omission both being reported about a quarter of the time. A list of the abbreviations considered “dangerous” by the Joint Commission on Accreditation of Healthcare Organizations is online. Sign up to receive e-alerts and newsletters on the health policy topics you care about most. The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. A medication error is any preventable event that may cause or lead to inappropriate medication use or harm to a patient. On March 11, 2008, FDA informed health care professionals about adverse events and deaths in children and adults who have taken Tussionex Pennkinetic Extended-Release Suspension (Tussionex).
Hydrocodone, the narcotic ingredient in this medicine that controls cough, can cause life-threatening breathing problems when too much medicine is given at one time or when the medicine is given more frequently than recommended.
Roughly 7,000 children ages 11 and younger are treated in hospital emergency rooms each year because of overdoses of OTC cough and cold medication, according to a recent study by the Centers for Disease Control and Prevention. OTC cough and cold products can be harmful if more than the recommended amount is used, if they are given too often, or if more than one product containing the same active ingredient is used. Serious injuries and deaths have resulted from such errors as misunderstanding directions and failing to use the measuring devices that come with the medicine.
To avoid accidental overdosing, consumers should not take more than the recommended dose on the label. FDA has issued warnings about the fentanyl transdermal system, an adhesive patch that delivers an opioid called fentanyl through the skin.

The directions on the product label and package insert of the fentanyl transdermal system should be followed exactly in order to avoid overdose.
FDA has issued a public health advisory cautioning practitioners to avoid overdoses when they are prescribing methadone or managing patients taking the drug. Since the 1970s, methadone has been primarily used in treating drug abuse, but it is increasingly being used to treat pain. Both edetate disodium and edetate calcium disodium work by binding with heavy metals or minerals in the body, allowing them to be passed out of the body through the urine. In January 2008, FDA issued a public health advisory, warning that some children and adults have died when they were mistakenly given edetate disodium instead of edetate calcium disodium (calcium disodium versenate), or when edetate disodium was used for chelation therapies and other uses not approved by FDA. To minimize drug name confusion, FDA reviews about 400 drug names a year that companies submit as proposed brand names.
FDA works with drug companies to reduce the risk of errors that may result from similar-looking labeling and packaging, or from poor product design.
In accordance with an FDA rule that went into effect in 2004, bar codes are required on product labels for certain drugs and biologics such as blood.
FDA reviews about 1,400 reports of medication errors per month and analyzes them to determine the cause and type of error. FDA is working on three new guidances—one on complete submission requirements for anaylsis of trade names, one about the pitfalls of drug labeling, and another on best test practices for naming drugs. FDA spreads the message about medication error prevention through public health advisories, medication guides, and outreach partnerships with other organizations. Note: If you need help accessing information in different file formats, see Instructions for Downloading Viewers and Players. Keywords: medication errors, medication errors nursing, medication errors canada, medication errors cno, medication errors in nursing canada, medication errors canada statistics, medication errors in pharmacy, medication errors in nursing homes, medication errors statistics 2015, medication errors in nursing ppt, medication errors may be common after hospital discharge . More than 6,000 times in 2003, in fact, medication errors were due, at least in part, to illegible or unclear handwriting. Such “dangerous” abbreviations, which were misinterpreted by pharmacists, nurses and patients, accounted for 4 percent of medication errors in that year, a number that has increased over the last five years. The USP has been collecting data on medication errors since 1998, and its most recent report includes analysis of more than 235,000 medication errors. The drugs most likely to cause harm or death when errors occurred and failed to be intercepted are opioid analgesics, anticoagulants and types of insulin. While the technology can help reduce errors, data from the USP shows that CPOE may need its own set of safety nets, because incomplete patient names, drug doses and laboratory test results are all making their way into systems and are contributing to drug errors. At the same time, the percentage of errors originating in the administering phase has decreased from 40 percent to 31 percent. Cousins cautions against reading too much into these data, noting that they may reflect a change in the definition of medication errors.
Cousins says that the USP is heartened by the fact that so many more health care organizations have decided that reporting medication errors outweighs any potential cost.
Perhaps even more encouragingly, the number of reports coming from those organizations has increased at a much greater pace. Cousins says, they would follow up after identifying a medication error by making changes in various processes and systems. Between 10 percent and 13 percent of medication errors each year can be attributed to factors Ms.
Cousins says the data show that while errors of omission happen most frequently, the types of errors that are most likely to end up causing patient harm are mistakes related to “wrong administration technique.” An example is crushing a sustained release tablet or pushing a medication rapidly that is supposed to be given over a minimum of an hour.
Since 2000, the Food and Drug Administration (FDA) has received more than 95,000 reports of medication errors. For example, miscommunication of drug orders can involve poor handwriting, confusion between drugs with similar names, poor packaging design, and confusion of metric or other dosing units. Overdose of Tussionex in older children, adolescents, and adults has also been associated with life-threatening and fatal breathing problems.

About two-thirds of those incidents occurred when children took medication without a parent's knowledge. In January 2008, FDA issued a public health advisory recommending that OTC cough and cold products not be used in infants and children under 2. For more information, see OTC Cough and Cold Products: Not for Infants and Children Under 2 Years of Age. The drug is sold under brand names such as Tylenol and Datril, and is also available in many cough and cold products, prescription pain relievers, and sleep aids. Also, acetaminophen should not be taken for more days than recommended, and should not be taken with other drug products that also contain acetaminophen without direction from a health care provider. For example, the infant drop formula is three times more concentrated than the children's liquid. Fentanyl patches should not be used for short-term acute pain, pain that is not constant, or for pain after an operation.
Recent reports to FDA describe deaths and life-threatening side effects after doctors and other health care professionals inappropriately prescribed the patch to relieve pain after surgery, for headaches, or for occasional or mild pain in patients who were not opioid tolerant.
The patients replaced the patch more frequently than directed in the instructions, applied more patches than prescribed, or applied heat to the patch. FDA issued the advisory because of reports of life-threatening adverse events and death in patients receiving methadone for pain control.
When used with bar code scanner and computerized patient information systems, bar code technology can help ensure that the right dose of the right drug is given to the right patient at the right time. About 10 percent of all health care institutions nationwide—typically those caring for inpatients—voluntarily and anonymously report errors to the Medmarx database.
Cousins notes that more near misses are being intercepted by pharmacists and nurses before they reach patients. In 2003, in fact, prescribing problems related to CPOE were the fourth leading cause of medication errors. Until recently, she explains, medication errors were typically viewed as any deviation from a prescriber’s order, because it was generally presumed that orders were correct. Hospitals and other organizations have often worried about the increased malpractice exposure or bad publicity of reporting problems.
The five-year data, for example, show little change in how hospitals react to the news that an error occurred, even one that was caught and fixed before it had a chance to reach and harm a patient. The patch is only for moderate-to-severe chronic pain that is expected to last for any number of weeks or longer and that cannot be managed by acetaminophen-opioid combinations, nonsteroidal analgesics, or as-needed dosing with short-acting opioids.
Like other opioids, methadone causes slowed breathing, affects heart rate, and can also interact with other drugs. Edetate disodium was approved as an emergency treatment for certain patients with very high levels of calcium in the blood or certain patients with heart rhythm problems resulting from high amounts of the medication digoxin in the blood. They include everything from insufficient, inexperienced, temporary and floating staff to cross coverage and increased workloads. An overdose can occur because methadone stays in the body longer than the pain relief lasts. In more than 40 percent of the cases reported to Medmarx, “distractions” were blamed the most for contributing to the error.
The study, published today in a Web Exclusive in the journal Health Affairs, finds that U.S.
Patient-reported errors were highest for those seeing multiple doctors or with multiple chronic illnesses.

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