STUDY SAYS SOUND-ALIKE NAMES KEY FACTOR IN MEDICATION ERRORS

February 1, 2011

According to the Institute for Medication Management, medication errors account for about 7,000 deaths and 770,000 injuries every year in the United States. It’s an issue the U.S. Food and Drug Administration has been working on for almost 20 years. A study released recently adds some insights into why many painkiller medication errors occur.

The researchers analyzed the prescription records of a teaching hospital and found more than 2,000 near-miss painkiller prescribing errors. Because medication errors are a “major contributor to suboptimal therapeutic outcomes and preventable adverse patient events,” the team wanted to determine if the medications had any commonalities that made them more likely to be involved in prescription errors.

What they discovered was that 2.87 errors in every 1,000 painkiller orders were pre-empted by pharmacists before the patient received the medication — these were the “near misses” at the center of the study. They also discovered that the error rate in pediatric patients was twice that of the rate for adult patients. The most errors occurred with the most commonly prescribed painkillers, but higher error rates were logged for drugs prescribed less often.

The nature of the errors varied widely, but a handful of factors accounted for 40 percent of all errors. They included dosage issues, including the availability of dose forms for multiple routs of administration, modified forms of dosage and atypical regimens. Also included were painkillers used on an ongoing, scheduled basis and, finally, sound-alike drug names.

It’s important to remember that not all medication errors are lethal. The study found that 0.63 out of every 1,000 prescription orders was “potentially serious.” About 14 percent of those were pediatric orders.

Source: Insurance Institute for Highway Safety, “Camera Enforcement in 14 Large Cities Reduces Rate of Fatal Red Light Running Crashes by 24 Percent,” 02/01/11

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