Medication Errors and Types Quiz

Medication Error Problem

• A study performed in 2000 estimated that 44,000 to 98,000 deaths per year are caused by medical errors, with 7,000 resulting from medication errors.
• The Institute of Medicine (IOM) report To Err Is Human brought the problem of errors to national attention.
• The report called for action to improve patient safety.

### Types of Medication Errors

• Wrong drug error: A drug that's not ordered for a patient is given.
  • Example: Furosemide 40 mg orally meant for a patient with an antibiotic.
• Extra dose error: A patient receives more doses than ordered.
  • Example: A patient receives their medication 5 times instead of 3.
• Omission error: A dose is skipped, though it was ordered.
  • Example: A patient is supposed to receive digoxin 0.25 mg orally in the morning but doesn't receive it.
• Wrong dose or wrong strength error: Wrong dose or strength is administered.
  • Example: Patient should receive warfarin 0.5 mg but receives 5 mg.
  • Example: Patient should receive timolol 0.25% but receives 0.5%.
• Wrong route error: A patient receives a dose through a route that's not ordered.
  • Example: Patient should receive prochlorperazine 10 mg intramuscularly but receives it intravenously.
• Wrong time error: Patient doesn't receive a dose at the time it was ordered.
  • Example: A patient with diabetes receives insulin 2 hours after breakfast instead of before.
• Wrong dosage form error: A patient receives a dose in a form that's not intended.
  • Example: Nicotinic acid 500 mg tablets are ordered but the patient receives 500 mg slow-release capsules.

Common Error Hazards

• Dangerous abbreviations: Numerous common abbreviations have been associated with errors.
  • U, IU: Should write out ‘unit(s)’ as ‘U’ can be mistaken as a number.
  • QD, Q.D., qd, q.d.: Should write out ‘daily’ as it can be misinterpreted as ‘QID’, meaning four times daily.
  • Q.O.D, QOD, qod: Should write out ‘every other day’ as it can be interpreted as ‘QID’, meaning four times daily.
  • Trailing Zero: Avoid trailing zeros, for example, warfarin 2 mg instead of 2.0 mg
  • Lack of Leading Zero: Include leading zero, so the dose is written as Digoxin 0.25 mg.
  • MS, MSO4: Should write out ‘morphine sulfate’ and ‘magnesium sulfate’ to avoid confusion.

Other Confusing Symbols

• cc: Use mL instead of cc.
• mg: Use mcg or write out ‘micrograms’ instead of mg to avoid confusion with milligrams.
• ,,, or .: Use “less than” or “greater than” in place of symbols.
• HCT: Write out ‘hydrocortisone’ as it can be misinterpreted as hydrochlorothiazide.
• HCl: Write out ‘hydrochloric’ as it can be misinterpreted as KCl, potassium chloride.
• Sound-a-like or look-a-like drug names: The ISMP has a list of confusing drug names.
  • Examples: Amitriptyline and aminophylline, Cisplatin and carboplatin, K-Dur and Cardura.

Examples of Common Medication Errors

• Example 1:
  • A pharmacist is presented with a prescription for 250 mcg of levothyroxine.
  • The accurate dosage would be 0.25 mg, but 2.5 mg was dispensed due to conversion mistakes.
• Example 2:
  • Community pharmacist mistakenly dispenses 10 mg of Warfarin instead of 1.0 mg.
  • This leads to the patient experiencing internal bleeding, almost leading to death.
  • This error was likely caused by a trailing zero in 1.0 mg, which could be misinterpreted as 10 mg.
• Example 3:
  • A hospital pharmacy mistakes a total parenteral nutrition solution for a cardioplegic solution for coronary bypass surgery.
  • This highlights the importance of identifying the root cause of the error during root cause analysis.

Test your knowledge about medication errors, their impact on patient safety, and different types of errors that can occur in medical practice. This quiz will cover key concepts highlighted in the To Err Is Human report and provide real-world examples to enhance your understanding.