Case Study Medical Error

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However, it is important to detect medication errors, whether important or not, since doing so may reveal a failure in the treatment process that could on another occasion lead to harm.

There is also evidence that the death rate from medication errors is increasing.

In a survey of 40 000 medication errors in 173 hospital trusts in England and Wales in the 12 months to July 2006, collected by the National Patient Safety Agency, ∼15% caused slight harm and 5% moderate or severe harm.

Since ∼3 billion prescriptions are dispensed each year in the USA, ∼50 million would contain errors.

A Venn diagram showing the relation among adverse events, ADRs and medication errors; the sizes of the boxes do not reflect the relative frequencies of the events illustrated (Reproduced from reference 8, with permission from Wolters Kluwer Health/Adis ©; Adis Data Information BV (2006); all rights reserved).); of those that are detected a minority actually result in ADRs, or at least serious ones.

For example, in a UK hospital study of 36 200 medication orders, a prescribing error was identified in 1.5% and most (54%) were associated with the choice of dose; errors were potentially serious in 0.4%.

A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient.

Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration).

The overlap between adverse events, ADRs, and medication errors is illustrated in the Venn diagram in Figure 1.

A Venn diagram showing the relation among adverse events, ADRs and medication errors; the sizes of the boxes do not reflect the relative frequencies of the events illustrated (Reproduced from reference 8, with permission from Wolters Kluwer Health/Adis ©; Adis Data Information BV (2006); all rights reserved).