Medication Errors, FDA U.S. Food and Drug Administration

FDA receives medication error reports⁴ on marketed human drugs (including prescription drugs, generic drugs, and over-the-counter drugs) and nonvaccine biological products and devices.  The National Coordinating Council for Medication Error Reporting and Prevention⁵ defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

The American Hospital Association⁶ lists the following as some common types of medication errors:

• incomplete patient information (not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results, for example);
• unavailable drug information (such as lack of up-to-date warnings);

via fda.gov

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When Nurse Make Mistakes (Theresa Brown, RN) - NYTimes.com

By THERESA BROWN, R.N.

This year, a Seattle nurse named Kim Hiatt committed suicide. Ms. Hiatt’s death came nearly seven months after she had given an unintended overdose to an infant heart patient, a medical error that was said to have contributed to the child’s death days later.

Ms. Hiatt had been a nurse for 27 years and had often cared for the 8-month-old girl during the child’s stay in the pediatric intensive care unit of her hospital. She had probably drawn up the right dose of the drug hundreds of times in her career. But once, she made a life-changing error. A baby died, and she was suspended, then fired from a profession she loved. And now she’s dead.

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Many paid caregivers lack health literacy skills :: May 4, 2011 ... American Medical News

More than a third of the people paid to care for seniors are not health literate, and 60% wrongly interpret the instructions on prescription labels, a study says.

Caregivers often are hired by families to help care for seniors with cognitive loss, dementia or Alzheimer's disease and who have trouble performing daily activities such as toileting, bathing, cooking and shopping. This makes it especially important that caregivers have the ability to understand health-related instructions, said Lee A. Lindquist, MD, MPH, lead author of the study published in May's Journal of General Internal Medicine (www.ncbi.nlm.nih.gov/pubmed/21161420/).

Caregivers' poor health literacy skills can affect patient care, said Dr. Lindquist, a geriatrician at Northwestern Memorial Hospital in Chicago.

via ama-assn.org

See also:

Death By Handwriting, By Maureen Glabman, Trustee Magazine :"Most Americans don't receive any formal handwriting instruction beyond the third grade, so how we learned to write then is more or less what we are stuck with for the rest of our lives. It's a worn joke that when someone writes poorly, we tell him he could be a doctor. But a medical error due to misinterpretation of illegible writing is no laughing matter--and for physicians it is a major threat to patient safety. The Joint Commission does not know precisely how often hospitals are reproached for handwriting deficiencies, but the problem is believed to be substantial. "The Joint Commission almost always finds instances where handwriting is of poor quality," says Peter Angood, M.D., JCAHO vice president and chief patient safety officer. The standard that encompasses handwriting legibility also includes stipulations that medical records be dated, that patients be identified and that diagnoses are supported, among other requirements, so it is difficult to sort out individual deficiencies."
http://www.trusteemag.com/trusteemag_app/jsp/articledisplay.jsp?dcrpath=TRUST.../PubsNewsArticleGen/data/2005/0510TRU_FEA_Handwriting

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amednews: 1 in 3 patients harmed during hospital stay :: April 18, 2011 ... American Medical News

By Kevin B. O'Reilly, amednews staff. Posted April 18, 2011.

One-third of hospital patients experience adverse events and about 7% are harmed permanently or die as a result, according to a study that detected patient safety problems at a far higher rate than other methods.

The study, in April's Health Affairs, echoes two reports issued in November 2010 that showed rates of adverse events hovering near 25% among hospitalized Medicare patients nationwide and at 10 North Carolina hospitals.

• Detecting adverse events
• Links
• See related content

The findings draw attention to the safety troubles that have lingered in U.S. hospitals in the 12 years since the Institute of Medicine's headline-grabbing report "To Err is Human." The study cited research estimating that up to 98,000 patients die each year due to preventable medical errors.

"This is one of the best studies that now gives us a sense of how much harm is happening to patients in American hospitals," said Robert Wachter, MD, chief of the medical service at the University of California, San Francisco Medical Center, who was not involved in the research. "There is a tremendous amount of harm befalling patients who are admitted to hospitals and humongous opportunities for improvement."

via ama-assn.org

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Nurse's suicide follows tragedy | Seattle Times Newspaper

By Carol M. Ostrom

Seattle Times health reporter

Related

Crisis help

Don't wait to seek help if you're in crisis.

In King County, call: 206-461-3222 (TTY/TDD 206-461-3219).

Outside King County, call 800-273-TALK (8255).

The suicide of a nurse who accidentally gave an infant a fatal overdose last year at Seattle Children's hospital has closed an investigation but opened wounds for her friends and family members, as they struggle to comprehend a second tragedy.

Kimberly Hiatt, 50, a longtime critical-care nurse at Children's, took her own life April 3. As a result, the state's Nursing Commission last week closed its investigation of her actions in the Sept. 19 death of Kaia Zautner, a critically ill infant who died in part from complications from an overdose of calcium chloride.

After the infant's death, the hospital put Hiatt on administrative leave and soon dismissed her. In the months following, she battled to keep her nursing license in the hopes of continuing the work she loved, despite having made the deadly mistake, friends and family members said.

To satisfy state disciplinary authorities, she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication, along with other conditions, said Sharon Crum of Issaquah, Hiatt's mother.

via seattletimes.nwsource.com

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Drug Errors on the Rise - NYTimes.com

The number of people treated in hospitals in the United States for problems related to medication errors has surged more than 50 percent in recent years.

In 2008, 1.9 million people became ill or injured from medication side effects or because they took or were given the wrong type or dose of medication, compared with 1.2 million injured in 2004, according to the Agency for Healthcare Research and Quality.

Although several national reports in recent years have sounded the alarm about the toll of medication errors, the latest data show the problem continues to persist. The A.H.R.Q. data measure only patients treated in the hospital or emergency department as a result of a medication error. The data don’t distinguish between prescribing, dispensing or consumer errors. Some of the errors resulted from a physician prescribing the wrong drug or dose; others occurred because a pharmacist or nurse gave the wrong drug, or because a patient at home used the wrong type or dose of medication.

via well.blogs.nytimes.com

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