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MEDICATION ERRORS

Definition: Medication error is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of 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, packing and nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use. Causes of medication errors: Errors of omission: This includes errors related to prescription, drug dispensing by the pharmacist, drug administration by medical personnel like nurses and patient themselves. Errors of commission: Most common form of errors encountered in the clinical practice. These include the following: 1. Wrong phenomenon: wrong drug, wrong dose, wrong substitution for a drug, wrong patient, wrong regimen (frequency, duration and timing of administration) and wrong route of administration.

2. Drug interaction related errors: Drug-Drug interaction, Food-Drug interaction or interaction with other alternatives forms of medicine 3. Communication failure: These are failures during the process of patient management and include illegible handwriting, incomplete prescribing order, vague instructions, prescriptions not recognized and unknown prescriber or illegible prescriber identification. 4. Failure to follow appropriate institutional and national policies related to drug use. 5. Failure to follow drug specific instructions provided on the label. 6. Overuse of a drug without therapeutic benefit commonly due to irrational drug use. 7. Other recognized types of medication errors are incomplete patient information, miscommunication of drug orders, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, inappropriate labeling and environmental factors.

Swiss cheese model: A pictorial model for medication errors called Swiss model has been described. The defenses against error are displayed as thin layers with holes that are described as latent errors in the system. Each layer successively represents the prescriber, pharmacist, nurse and patient related defenses. If an error is missed successively at various defense levels, the medication error reaches the patient. Drugs commonly associated with medication errors: Analgesics: Unnecessary use of opioid analgesics may be responsible for over-sedation in patients receiving the drug. Med-

ication errors are reported due to wrong route of administration and failure to monitor clinical parameters. Antibiotics: Irrational use of antibiotics when the clinical condition doesnt warrant the use of these agents. Anticoagulants: Inadequate therapeutics dosing and failure to monitor the blood values. Cardiovascular agents: Overdose and lack of monitoring of haematological parameters during therapy. Diabetic medications: Overdose of hypoglycemic drugs mainly insulin, due to lack of knowledge, usually due to improper patient education.