Medication Errors

Hospitals are obligated to provide the correct medicine to the right patient, in the proper dose, for the right reason.  Nonetheless, at least 1.5 million medication errors occur every year in hospital, long term care facilities, and outpatient clinics.  According to the Institute of Medicine, a patient in a hospital will likely suffer, on average, at least one medication error every day!  It is estimated that as many as 120 patients die in hospitals as a result.

Overdoses, giving the wrong medications, and ordering multiple medications that are incompatible happen for various reasons, but almost all are the result of systemic failures in the medical facility.

When we prepare medication error cases, we look for the root cause—was it a human error such as misidentification of a medication, confusion over names and packaging that look the same, or failure to administer a dose?  Or was it due to high-level managerial decisions related to equipment, technology , maintenance staff or communication?  These weaknesses exist in the medication system long before the event occurs—the accident waiting to happen.