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However, it is important to detect them, since system failures that result in minor errors can later lead to serious errors.Reporting of errors should be encouraged by creating a blame-free, non-punitive environment.
From 1983 to 1993 the numbers of deaths from medication errors and adverse reactions to medicines used in US hospitals increased from 2876 to 7391 These increases are not surprising—in recent years hospitals have seen increased throughput of patients, new drugs have emerged that are increasingly difficult to use safely and effectively, medical care has become more complex and specialized, and the population has aged, factors that tend to increase the risk of medication errors.
The best way to understand how medication errors happen and how to avoid them is to consider their classification, which can be contextual, modal, or psychological.
The overlap between adverse events, ADRs, and medication errors is illustrated in the Venn diagram in Figure 1.
A Venn diagram showing the relation among adverse events, ADRs and medication errors; the sizes of the boxes do not reflect the relative frequencies of the events illustrated (Reproduced from reference 8, with permission from Wolters Kluwer Health/Adis ©; Adis Data Information BV (2006); all rights reserved).
An error is ‘something incorrectly done through ignorance or inadvertence; a mistake, e.g.
Case Study Medical Error
in calculation, judgement, speech, writing, action, etc.’The term ‘failure’ in the definition implies that certain standards should be set, against which failure can be judged.
A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient.
Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration).
The term ‘adverse drug event’ is sometimes used to describe this, but it is a bad term and should be avoided.
If an adverse event is not attributable to a drug it remains an adverse event; if it may be attributable to a drug it becomes a suspected ADR.