June 19th, 2010 
meilan Medication errors: An abuse of patient Kamal Shah1 *, Nagendra Ku Singh2 Jiteendra. Gupta1 and Pradeep Mishra3 Lecturer, Institute of Pharmaceutical Research GLA, Mathura (UP) *, 1 Fellowship, Dr. HS Gour University, Sagar (MP) 2 Director of the Pharmaceutical Research Institute of GLA, Mathura (UP) 3 A medication error is a preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the physician, patient or consumer. “One or medication errors, defined as a error in prescribing, dispensing or administering a drug, if there are adverse consequences or not, are the leading cause of preventable injuries to patients. 2.3 These errors can, every step of the process of consumption drug to prescribe for the administration to occur for the patient. A recent report by the Institute of Medicine (IOM) estimates that errors in medical management from 44,000 to 98,000 deaths per year due to hospitals in the United States. In the U.S., it has been suggested that the rate of serious medication errors is about 7%. 4 Examples 5-6 1) Hydrocodone is an ingredient that controls cough drugs, shortness of breath life may, if it is given in an overdose or if the drug is administered more frequently the cause. It should not be used in children under 6 years. On March 11, 2008, the FDA reports suggest that patients in health care for youth that age group has approved 6 years and older, more often than the dosing interval after 12 hours every prescribed hydrocodone (“extended release”), and that patients have the wrong dose caused by a misinterpretation of guidelines dose. 2) A physician ordered a 260-mg preparation of Taxol for a patient, the pharmacist prepared 260 milligrams of Taxotere instead. Both are chemotherapeutic agents for different types of cancer, and with different recommended doses used. The patient died a few days later, when death is not the errors are linked because the patient was already seriously ill. 3) An elderly patient with rheumatoid arthritis died after receiving an overdose of methotrexate – a dose of 10 mg of the drug, instead of the future 10-mg weekly dose. Some dosing mix-ups have occurred because daily dosing of methotrexate is commonly used to treat people with cancer, while low doses of the drug weekly for other diseases such as arthritis, asthma were prescribed, and chronic inflammatory diseases of the intestine. 4) The patient, because 20 units of insulin “has been shortened 20U died, but the” U “for a” zero “bad”. Therefore, a dose of 200 units of insulin was injected by mistake. 5) A man died after his wife mistakenly applied six transdermal patches to his skin at once. Multiple spots of an overdose of narcotic analgesic fentanyl provided by its skin. 6) A given patient developed a fatal hemorrhage when another patient prescription for the anticoagulant warfarin. There are several causes of medication errors that is poor communication, misinterpreted handwriting confusing name drugs, lack of employee knowledge, and lack of patient understanding of directions on a drug. In most cases, medication errors can not be responsible for one person to do. Types of medication errors Medication errors can be roughly classified in prescribing, dispensing or administering medication error: Prescription errors prescribing errors can be defined as a false choice drug for a patient, whether the dose, strength, route, quantity, indication, cons-indication. 7 Dispensing errors dispensing errors occur at any time during the processing of distribution accounts for the receipt of a prescription to the pharmacy to deliver a product for the patient. These errors include the selection of the wrong dose / product. This happens especially when two or more drugs, a similar appearance or similar names (look-a-like/sound-a-like errors). Other potential tax errors are wrong dosage, wrong drug, wrong patient. 8 Administration Errors The “five rights” have long been the basis of nursing education on drug administration to give the correct dosage of the right drug to the right patient at the right time the right way. Include Drug Administration substantial errors, errors omission, where the administration abandoned due to various factors, e. g the wrong patient, the lack of stock. Other kinds of medication administration errors are the technical administration of evil, the administration of expired drugs and poor preparation administered. 90-10 Other factors that are prescribing errors: 11 Illegible handwriting Confusion inaccurate history of medicine in the names of drugs misuse of decimals using abbreviations use of verbal orders Lack of knowledge about the prescribed medication, can help the recommended dose and patients on prescription errors. Other factors are poor tax procedures with insufficient control, unreasonable workloads and poor standards of financial management. Studies have also supported a relationship between errors and the distribution of changes in light level, the workload limitation and noise. It is suspected that distractions and interruptions lead to performance errors. In addition, no dose exceptionally difficult, the distribution of products unknown distribution, a written order before it can lead to errors. 12 Methods to minimize drug Errno13 Medication errors can be avoided as follows: – Changes in the system of ordering, dispensing and administering medicines. – The use of computerized order entry physicians. – The correct recognition of a drug before prescribing – Print the name of the drug and the patient clearly on the prescription – Contains all the details to say the name of the drug product, dosage, mode, duration of treatment – Do not let a comma “naked. A zero should always precede the expression of values e. g 0th First error rate is ten times due to the use of a final zero. – Avoid using abbreviations, such as AZT, ISMN, FeSO4, U. – Knowledge of products-a-like sound. Barcode rule Suggest decided, after a public meeting in July 2002, the FDA a new provision of bar codes on certain drug and biological product labels. Health professionals would use bar code scanning equipment, even in supermarkets to ensure that the right medication given to the proper dosage and method of administration, the right patient at the right time. Drug name confusion: To minimize the appearance of confusion between drug names that sound or are the controls the FDA has about 300 drug names a year before they are marketed. The agency tests drug names with around 120 health experts from the FDA, which simulated on a voluntary basis, real situations of the drug. The last time the FDA changed a drug name after it was approved in 1994, when the thyroid medication Levoxine be confused with the heart medicine Lanoxin (Digoxin) and some people were admitted to hospital following . However, the medicine of the thyroid is Levoxyl, and the agency has received more reports of errors since the name change. The labeling of drugs: The label clearly indicates the active ingredients, warnings, dosage, directions, other information such as how to store drugs and excipients. 14 The reduction in dispensing errors made by: The use of safe dosing. With different brands or products, the separation of-alikes. Focusing on the task at hand hold, interruptions to a minimum and keep their workload at a level of security and manageable. Aware of the high-risk drugs such as potassium chloride, cytostatics Presentation good environmental practices. administration errors of drugs can be reduced by: Free to the patient’s identity. dosage calculations for independent verification before the drug is administered. Ensure that the drugs administered at the right time. Completion As health professionals is a prescription, ask the name of the drug to say it is the right mix, and consumed the drugs. Make sure that the instructions for all medications correct dosage, storage requirements and include any special instructions. At the hospital, ask (or ask a relative or friend) is given the name and purpose of each drug. Make sure the doctor the names of all prescription and nonprescription, said dietary supplements and herbal preparations you are taking, whenever he or she will write a new prescription. This will prevent any other kind of drug problem, drug interactions and potentially serious side. Finally, never be afraid to ask questions. If the name of the medicine looks at the recipe is different from that expected if the different directions, as thought, or if the pills or drugs still seems different, talk to your doctor or pharmacist immediately. Ask questions if you want to have suspicions of a free and easy way to ensure you do not become the victim of a bug drugs. Each share of responsibility for physicians to identify factors of medication errors and use this knowledge to reduce their frequency. Both experienced staff may be responsible for medication errors. A multidisciplinary approach to solve this problem should be encouraged to be with all parties concerned, the issue of reducing medication error occurrence address. Development of a multidisciplinary approach has been slow, probably due to the reluctance or refusal to admit the doctor, pharmacist or nurse for a medication error. References: First http://www. nccmerp. org / aboutMedErrors. html Am J Health Syst second-Pharm 1995, 52:379-82. 3rd BMJ 2000; 320:774-7 4th NEJM 2000 342: 1123-5. 5th www. FDA. gov/bbs/topics/NEWS/2008/NEW01805. html 6th www8. nationalacademies. com / onpinews / newsitem. aspx? RecordID = 11623 Am J Hosp Pharm 7th 1993, 50:305-14 8th C & D 1997 (February), P1-P2 Am J Health Syst ninth-Pharm 1995, 52:390-5 The 10th Drug Safety 2000, 22:321-33 Am J Health Syst 11-Pharm 1995, 52:382-5 Am J Health Syst twelfth-Pharm 1995, 52:369-416. 13 Drug Safety 1996; 15: 303-10. 14th www. FDA. gov/consumer/updates/medicationerrors031408. html
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