Medication Error

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A medication error is an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication (Agency for Health Care Research and Quality, 2019). 

In a study conducted by Da Silva and Krishnamurthy (2016), they state that preventable medication errors impact more than 7 million patients and cost almost $21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors are an underreported burden that adversely affects patients, providers, and the economy. The study involved a 71-year-old female who accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes and had multiple hospital visits within the 3 months. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Admission medication reconciliation (MED REC) revealed that she was taking metoprolol, doxazosin, alprazolam, citalopram, and thiothixene (Navane) 10 mg twice daily. Upon review of her pill bottles, it was found that her outpatient pharmacy accidentally dispensed Navane (an antipsychotic) instead of Norvasc, and she dutifully took this medication for 3 months. The written prescription was deemed legible. A diagnosis of thiothixene-related drug-induced Parkinsonism was made. Thiothixene was discontinued and her clinical status improved.

Da Silva and Krishnamurthy (2018) note that important steps to prevent medication error include clear patient instructions with indications for use on every prescription, utilization of EHR medication import (when available) to review outpatient prescription history, and creating a culture within the medical field of error discussion. Possibilities include medication teams who review admission and discharge reconciliations, team rounding with a pharmacist, encouraging postgraduate trainees and faculty to question indications and utility of medications, and distribution of national and institution data regarding errors, and adverse events. Mandatory training should occur for those providers who fail to document and reconcile medications properly.

As a nurse practitioner it is important to monitor the patient especially when poor treatment response occurs or unusual symptoms develop, it is imperative that a review of medications and pill bottle review be part of the initial evaluation. I will implement and use multilevel safeguards, starting with error recognition. Medical error was recently described as the third leading cause of death and only by creating a culture of humility, communication, and teamwork can we learn from our mistakes and hope to decrease preventable errors.

References

Agency for Health Care Research and Quality. (2019). Medication Errors and Adverse Drug Events. Retrieved from https://psnet.ahrq.gov/primers/primer/23/Medication-Errors-and-Adverse-Drug-Events

Da Silva, B., Krishnamurthy, M. 92016). The alarming reality of medication error: a patient case and review of Pennsylvania and National data. Retrieved from https://www.tandfonline.com/doi/full/10.3402/jchimp.v6.31758

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