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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. 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.
In a slip and fall case can you infer the grocery store had knowledge of the substance on the floor? How Do You Know If A Business Acted Reasonably In Trying To Prevent an Office 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. This article was written on 21 Sep 2015, and is filled under Volume 10 2015, Volume 10 No 1 & 2. Purpose: Wrong-time medication administration error (WTMAE) is a high risk to patient safety. Setting: Data was gathered from a private tertiary care university hospital in Karachi, Pakistan.
Implications: Medication administration is a complex process, and WTMAE is a major area to focus for improving the accuracy of medication administration recording. Value: Technology used innovatively in the form of eMAR can significantly help in identifying medication administration errors (MAE). Patient safety issues related to medication administration are critical on a day by day basis.
Studies have been conducted to identify MAEs and wrong-time medication administration error (WTMAE) as high risk to patient safety.

The purpose of this study was to investigate the prevalence of WTMAE with the help of technology and to explore factors contributing to WTMAE. A literature review was done using different search engines such as Pub-Med, EBSCO host CINAHL Plus and Cochrane Database of Systematic Reviews.
The study was conducted at a private tertiary care university hospital in Karachi, Pakistan. A universal sampling technique was used to capture all the medication doses prescribed for the 3-month period from February 10, 2012 to May 9, 2012. Data received from the eMAR was coded for different variables and analyzed in SPSS version 19. The results illustrate that, overall 250,213 doses were prescribed for all of the five selected inpatient locations during the study period of 90 days.
Figure 2 summarizes the percentage of on-time and wrong-time medication administration record by locations. Data was also analyzed to measure WTMAEs in different shifts to identify the impact of shifts on WT errors. The eMAR system was programed to allow nurses to administer a medication dose 60 minutes prior or later to its scheduled time only after giving a short reason. The data on WT medication administration errors illustrates that error identification from electronic system helps to give accurate number of errors and avoid any Hawthorne effects on the study; whereas the literature search revealed that most of the previous studies used observational methods to gather medication administration error data (Bates,. As a System Analyst, I am involved in the planning, development and implementation of different clinical systems to enhance technology in nurses.
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.
MASSACHUSETTS BOARD OF REGISTRATION IN NURSING A Study of Selected Complaint Cases to Identify Evidence-based Strategies to Prevent the Occurrence of Nursing. 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. 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. The study highlights the frequency of WTMAEs and provides opportunities for improvement in nursing practices by elaborating multiple reasons for WTMAEs.
Among all types of clinical errors, medication administration errors (MAEs) are reported as the second most frequent cause of injury. The National Patient Safety Agency (NPSA) News (2007) reported that WTMAE is the second largest category of medication error reported worldwide and has resulted in death or serious harm to patients. This study compared actual versus expected medication administration time, captured from an electronic medication administration recording system (eMAR).
Attempts were made to find the literature from the primary source library and some of the literature was explored through secondary sources (University of Sheffield) library.All electronic databases were searched for references with key terms such as medication error, medication administration error and wrong-time medication administration errors.
Data for this study was gathered through the eMAR system, which identified the dose timing (actual verses expected) with reasons for early or late administration.
This activity was initiated only after getting approval from hospital departmental heads and the ERC. Additionally Chi-square test was used to analyze data for differences between wrong-time administration verses on-time administration at different locations and shifts, to identify any significance difference. The finding indicates that out of 250,213 prescribed doses 231,380 doses were administered whereas 18,833 doses were not administered (see Table 2). The data showed 17% prevalence of WTMAEs at the tertiary care university hospital in Karachi, Pakistan. This systemic intervention helped us to identify many reasons for early or late medication administration errors.
The most important contribution of this study was the focus on wrong-time medication administration errors and their contributing factors. International studies conducted on wrong time error were reported using observational and chat review methods via manual medication administration record.

Currently work as a Lead Analyst Nurse working with EHR Core Committee for selection of suitable software for Electronic Health Record for all the Aga Khan Hospitals in Asia & Africa. 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. 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. Through this study we investigated the prevalence of WTMAEs via electronic medical administration record (eMAR) and explore the contributing factors associated with WTMAEs. Therefore research needs to be done to identify different types of medication administration errors such as, wrong patient, wrong dose, wrong route, wrong drug, wrong-time and many others. The study was conducted at a tertiary care hospital in Pakistan where the electronic medication administration record (eMAR) was used at all inpatient locations. These reasons were further grouped to list 35 reasons (Table 3) for late administration and eight reasons (Table 4) for early administration. Our study results showed a total of (n=39,386; 17%) doses in error due to WT administration in a three month period. The study shows that innovative technology and its role in identification of MAE and WTMAE are imperative and well supported by the literature.
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.
Upon further exploration of WTMAEs multiple reasons for late and early medication administration were identified. Identification and analysis of MAEs are highly important for process improvement and patient safety. The study findings provide an opportunity to decrease patient care risk and assist in development of different strategies for system improvement to ensure safe practices.
Pub-Med search revealed 1642 articles, EBSCO host CINAHL Plus provided 220 and the Cochrane database revealed 1551 full text articles with search term: “medication error”.
These units were chosen to cover most of the specialty areas for adult and pediatric patients with medical and surgical conditions. Figures 4 and 5 depict the top five reasons for late and top three reasons of early administration. The data also displayed how timing errors are not considered a major issue and have been given less attention. Electronic medication administration record systems act as a great tool to capture the administration record in a timely manner and to help to correctly estimate the prevalence of WTMAE and the reasons behind the wrong-time administration. This study’s finding suggest that staff members ought to be sensitized to the importance of on-time medication administration, which requires strong enforcement by management in the form of institutional policy. 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.
According to Koppel, Wetterneck, Telles, and Karsh (2008) “The Institute of Medicine (IOM) estimates that, on average, a hospitalized patient is subject to one medication administration error (MAEs) per day… In hospitals, the medication administration stage accounts for 26% to 32% of adult patient’s medication errors” (p.
The search was narrowed to search term “wrong-time medication administration error” which revealed limited full text articles. Approval for data collection was requested from relevant departmental heads and the hospital Ethical Review cCmmittee (ERC). It has been mentioned by Fitzhenry et al., (2007) that“the effects of timing errors and errors of omission were rarely recognized clinically” (p. Also regular audits of medication administration records in the eMAR should be done to check for WTMAE. Doctors may ignore or overlook compromised kidney or liver function, failing to reduce doses or discontinue harmful drugs.
The senior management must also be apprised of the fact that to create a culture of patient safety, correct nurse-patient ratios are important to curtail WTMAE. 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. Allan and Barker (1990) suggested that wrong-time errors were defined as deviations from hospital policy.

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