The results of a pharmacy getting the wrong medication can be devastating, and even fatal. A Johns Hopkins Medical report claims medical errors are the third leading cause of death in America.
Medication errors account for more than one million emergency room visits each year, according to the Center for Disease Control.
The question is, what causes medication errors? Join us as we explore several common reasons for these mistakes. We’ll also dive into point-of-care medication dispensing and the role it plays in preventing patient harm.
What Are Medication Errors?
A medication error is defined as any event that can be prevented but due to error on the part of the physician, pharmacist or patient, causes harm to the patient.
Pharmacists are busy. They receive hundreds of orders every day from patients who want their prescriptions filled immediately. Because of this type of pressure, it is easy for a pharmacist to miss the mark in various stages of the prescription filling process and hand out the wrong medication or otherwise mess up.
These errors can range from minor oversights with little to no impact on the patient to major mistakes that can lead to severe health complications or even fatalities. Some of the basic types of medication errors include:
Underdosing
Underdosing is perhaps the least dangerous type of medication error. In this scenario, the patient receives the right medication, but they receive less of it than they should. The impact of this mistake varies based on the importance of the medication and individual patient risk factors.
For instance, underdosing an antibiotic may allow a bacterial infection to run rampant, drastically worsening patient outcomes. Conversely, underdosing a prescription pain medication may have minimal impacts.
Overdosing
Overdosing can occur both when prescribing medications and administering drugs in health care settings. Either instance can be incredibly dangerous to the patient, especially when drugs are given intravenously, as they will have a rapid onset.
Overdosing is particularly dangerous in the pediatric setting, as most drugs are weight-based. However, adults can also suffer severe harm if they take too much medication. Fortunately, the dosage amounts of many drugs, including controlled substances, are administered in standardized increments. This practice helps reduce the likelihood of overdosing patients.
Providing the Wrong Medication
Many drug names sound alike, especially when using their abbreviations. Unfortunately, medication names that sound or look alike can cause patients to receive the wrong medication. Distributing the wrong meds has the potential to yield some of the most severe side effects.
Another possible cause of this issue is linked to a poor understanding of medication repackaging guidelines. Make sure that your suppliers and pharmacy partners strictly adhere to repackaging rules, including those about labeling.
Common Causes of Medication Errors
Misinterpretation of Prescriptions
Healthcare providers who use handwritten prescriptions must ensure that their handwriting is legible. Illegible handwriting can result in medication fulfillment delays or, worse, prescription errors. The easy solution to this problem is to transition to an electronic system.
Establishing an electronic reporting system will reduce error rates and allow you to easily disseminate prescription data to pharmacists. However, electronic medication orders aren’t foolproof.
If you want to maximize error reduction when using electronic prescription systems, make sure that you avoid abbreviations and type out the full names of medications. This is especially important when dealing with high-risk drugs. Also, avoid unclear instructions, and be very detailed regarding dosages and frequency. It’s imperative that you don’t leave anything to chance or interpretation.
Similar-Sounding Medications
Look-alike, sound-alike (LASA) medications are notorious for causing confusion among pharm teams. Medications with similar names or packaging can be mixed up easily, leading to patients receiving the wrong medications. This issue underscores the need for careful attention to detail and the implementation of checks to distinguish between such medications effectively.
These drugs have names that sound similar when spoken, or they look alike in written form, especially on handwritten prescription slips. For example, the sedative “lorazepam” and the antipsychotic “olanzapine” sound similar, increasing the risk of mix-ups. Imagine how similar these drugs would appear on a hastily written prescription slip.
Similarly, “hydroxyzine,” used to treat itching and anxiety, and “hydralazine,” a medication for high blood pressure, have names that can easily be confused. Addressing these risks requires heightened awareness and strategies to differentiate these medications clearly.
During dispensing, staff should use medication reconciliation strategies to perform a second phase of verification. This is especially important with high-alert medications, such as controlled substances and drugs with a high propensity to cause adverse effects.
High Workload and Fatigue
One of the major reasons for medication errors is pharmacist fatigue. The pharmaceutical dispensing sector is experiencing a high workload and a nationwide staff shortage. This combination of circumstances has created a perfect storm, opening the door for poor communication, erroneous order entry, and an increase in dispensing of the wrong medication.
There is also a large shortage of pharmacy techs. In a 2022 survey, 81% of respondents reported problems with finding enough pharmacy technicians to fill vacant positions. As you can imagine, all these shortages are placing added strain on pharmacy workers and increasing the likelihood of errors.
Lack of Communication
Inadequate communication between healthcare providers, including doctors, nurses, and pharmacists, can lead to medication errors. Clear and effective communication is essential for accurate medication management, ensuring that all parties have a consistent understanding of a patient’s medication regimen.
Consider how your practice relays prescriptions and patient information. Is your current process standardized across all pharmacies, or do you have to use a different approach with each pharmaceutical partner? A lack of standardized communication workflows increases the prevalence of near misses and outright medication errors.
Technology Issues
While technology plays a critical role in modern healthcare, overreliance on electronic health records or dispensing systems can introduce its own set of problems. Glitches or errors in these systems can lead to incorrect medication being prescribed or dispensed, highlighting the need for ongoing vigilance and verification processes.
Remember, too, that healthcare systems still rely on human inputs. If parties at either end of the transaction make a mistake, it can increase the incidence of error. Therefore, training your team and implementing checks and balances are crucial steps. By establishing layers of redundancy and verification, you increase your odds of catching any errors that enter your system.
What Can Happen If the Patient Receives the Wrong Medication?
Patient Can Have a Negative Reaction
Pharmacists can accidentally get medicines mixed up. Some medicines have similar sounding names. Some have similar shape, size and colors. When compounding and sorting multiple medicines on the same counter, mix-ups can happen and the wrong medication could be given.
Accidents like these can lead to allergic reactions in patients who trust the pharmacist to get it right.
Allergic reactions can vary from person to person. Hives and rashes can appear on some people who are dealing with a negative reaction. Some may get a high fever, while others may feel their airways swelling or closing from the wrong medication.
Nausea, vomiting, itchiness and coughing are signs to watch for. They will be quite noticeable, making you feel very uncomfortable.
Wheezing and difficulty breathing are more serious symptoms of an allergic reaction. It is important to get medical treatment immediately for any of your reactions, especially to avoid an overdose from the wrong medication or amount.
Patient Can Overdose
Overdose means to take too much of a substance. In this case, it means a patient taking too much of a prescription medicine. When learning about overdoses, you must understand that to overdose, there must be a dose that is first considered safe.
The prescribed dose is the amount the doctor feels will be most effective for treating the patient’s ailment. If someone takes more than the base dose, overdose can become a reality.
Overdoses can be intentional, accidental or due to pharmacist error.
An overdose can happen when a patient takes a higher dose of a medication than they should have. An overdose can also happen when a patient takes the wrong medication, thinking it was the right medicine. Furthermore, an overdose can happen when a patient takes too many medications.
All these are often mistakes created at the pharmacy.
Whether the pharmacist misread the doctor’s prescription or put a label on the medicine with a typo, overdoses do take place way more often than they should.
Patient Can Die
There are several cases in which a patient has been given the wrong medication or the wrong dose of a medicine by a pharmacist and it has lead to their death. On top of all the pain and heartache this creates, it also sets up a pharmacist for a major lawsuit.
Take the case of a young boy who was given the wrong medication by a pharmacy that was 1,000 times higher than prescribed. Errors like this are devastating for everyone involved. It is devastating because these errors are preventable.
How to Avoid Wrong Medication With Physician Dispensing
It is becoming more and more clear that dispensing at the point of care is the safest way to help patients receive the right medication at the right dose for treatment.
The most noticeable benefit is safety and reduction in medication errors including the wrong medication or wrong strength.Physicians can prescribe medications and fill those prescriptions using prepackaged medication, which arrives in individual doses contained in blister packaging for added safety.Prepackaged medication can be ordered for the specific amount of medicine needed versus getting a bottle full of pills that make it easier for a patient to take more than needed.
Storing and accessing prepackaged medicines are easy for you. When you prescribe a prescription, you simply retrieve it from a locked cabinet in your office. The next step is for you to print the label.
Ensuring information is correct on the label is very easy to do when prescribing at the point of care. The information you enter into the computer is automatically printed according to compliance laws in order to avoid giving out the wrong medication or wrong instructions. To further safety, the computer software can alert you if there are interactions between medications.
It makes you verify the information before printing. And because you have hundreds less prescriptions to fill, you have the time to make this effort a priority.
The software can also alert you to when refills are needed for a patient. This ensures they are not missing any doses and having a lapse in treatment.
Minimize Pharmacy Errors With In-Office Dispensing
Physician dispensing represents a significant paradigm shift in medication management. It offers a comprehensive strategy for mitigating medication errors, streamlining the medication process, and implementing effective preventive measures.
By ensuring your direct involvement, you can enhance efficiency and provide a more informed and centralized treatment journey. In turn, this may lead to better patient outcomes and higher satisfaction.
Are you ready to learn more about how in-office dispensing works? Proficient Rx can provide you with resources and technologies designed to elevate medication safety through in-office dispensing. Contact us to discuss the needs of your practice.
