Medication Errors: The Risks We Must Reduce

By Maryann Small, Director, Data Governance & Business Analytics

The importance of reducing medication-related errors reached a pivotal and very public moment in 1994. Two patients at the Dana-Farber Cancer Institute received major overdoses of chemotherapy drugs ― one patient, The Boston Globe’s award-winning health columnist Betsy Lehman, died and the other patient suffered permanent heart damage. The world was suddenly watching very closely as organizations and health providers moved swiftly to improve patient safety by implementing new processes and technologies for the ordering, dispensing, administration, monitoring, and management of medications.

That pivotal moment in the patient safety movement resulted in many significant advances, particularly information technology (IT) systems that can perform vital tasks, like automating the ways in which medications are selected, providing accurate dosing details, providing notification of drug/drug interactions, and triggering automated reminders so hospital staff know when to administer the next dose. Yet for all those remarkable improvements, medication error still remains one of the top causes for patient safety events and subsequent claims.

What the Data Tells Us
A recent root-cause analysis of 11,000 medication-related closed claims at Coverys revealed:
  • Medication-related errors are the fourth most common type of liability claim (more prevalent even than obstetrics-related claims).
  • The highest percentage of alleged medication errors (44%) occurred in an office or clinic setting.
  • 41% of alleged medication errors were related to inappropriate monitoring of a patient’s medication regimen.
  • Almost 40% of cases in which the root cause of the claim was medication error ultimately involved a patient death.
  • The overwhelming majority of medication-related claims stem from general medicine (internal, family, etc.), followed in frequency by medical sub-specialties, anesthesia, emergency, surgery, and psychiatry. 
  • Situations involving opioids and anti-coagulation drugs represent the highest percentage of medication-related claims, followed by antibiotics; these three types of medications account for 50% of indemnity paid.
  • Hormones (particularly insulin overdose) and cardiovascular agents, while involved in a relatively small number of cases, result in some of the highest indemnity payouts.
  • All medication-error claims combined accounted for 6% of total indemnity paid.
 Our analysis reveals that medication errors happen at every step of the process ― from ordering the wrong medication, to incorrect dosing, to monitoring and management. But it’s the beginning and the end of the medication process where the most errors happen ― when the practitioner initially orders the medication (accounting for the highest percentage of medication-related claims) and at the monitoring and management phase (accounting for the second-highest percentage of medication-related claims and the highest percentage of indemnity paid).

Why are errors occurring? A lack of vigilance in medication reconciliation is one of the key causes of medication-related claims. While technologies have significantly improved the selection, dispensing, and administration of medications, the work of medication reconciliation is losing steam. Medication reconciliation ― ensuring that the full collection of various medications any given patient is taking are still safe, necessary, and appropriately dosed ― requires impeccable processes and clear communication as patients move across the continuum of care where ongoing medication adjustments are made.

Ten years ago, much work was done in the healthcare industry to focus on the importance of medication reconciliation; healthcare workers were encouraged and required to ask, at every patient encounter, “What medications (prescription and over-the-counter) are you taking? What supplements are you taking?” Medication lists were continually reconciled and patients were ultimately safer. At some general medicine practices and even hospitals, patients were given little “medication list” cards for their wallets, and these lists were kept up to date and replaced at regular intervals. Unfortunately, that’s not always the case anymore.

Lessons Learned
When it comes to making patients safer, conversations between provider and patient, and the routine activities surrounding medication are paramount. It’s these “everyday” or “routine” decisions, interactions, and processes surrounding the ordering, dispensing, administering, monitoring, and management of medication that can and must be handled better. “Taking your medicine” is no small thing, and nearly everyone on the healthcare team ― from the medical technician to the physician to the pharmacist ― has a vital role to play.

No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances. 

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