How can I protect against prescription errors and how do I talk with kids about it?
From the FDA's website: Within the Center for Drug Evaluation and Research (CDER), the Division of Medication Error Prevention and Analysis (DMEPA) reviews medication error reports on marketed human drugs including prescription drugs, generic drugs, and over-the-counter drugs. The DMEPA uses the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) definition of a medication error. Specifically, a medication error is "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the 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, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."
I know, that seems like a lot of useless acronyms, however, performance in these areas may never improve if it wasn't for these agencies and councils. In case you were wondering who was looking at this, now you know some of the groups. The most significant thing here is the definition of a "medication error," which helps us all get on the same page about the criteria. If someone has a reaction to a drug, and the allerigy was unknown until the drug was administered, that would not constitute an error, even if there was consequence (harm). Notice that the differnt methods are highlighted, but "harm" is not defined. My current perception is that harm would be something that causes the patient discomfort, injury, or has lasting effects.
I recently attended some Human Performance training, where the instructor stated 25% of all medications distributed through a pharmacy are in error of some kind through a misguided chain (insert Reason's swiss cheese model here.) Doctor writes the prescription - nurse sends to pharmacy by phone, email or fax, or the customer takes it there - Pharmacist reviews it and potentially fills it or directs a tech to - Pharmacy technician (with potentially little or no experience) fills it - customer takes it home and uses it. Can you see where some problems may exist? Type of drug type, dosage and intervals are the three key factors, right? In today's world we can go online and find a picture of what the pill we got looks like and make sure it's the correct drug, but we have to put extra trust into the system when it's a liquid we are giving to our children. How can a parent or patient verify a liquid? I don't know about you, but this is a part in the process I would like to see improved.
So, what can you do about it?
Always assume a mistake was made. My suggestion is to start with a small amount - many lotions or creams say to start with a small application to ensure you do not have a reaction to it, prior to applying the normal amount. Not necessarily a great precautionary measure for the unknown. {Opinion Alert} It's really too bad in all the years we've had such a warning, we have not come up with something better than "try a little."
Click here to find out what they FDA is doing about it.
Click here to find out what Purdue University's research found. I really appreciate the holistic approach and less blame on front line workers, recognizing that people make mistakes, and how can the system prevent it.
What about dosage?
In the book "Why We Make Mistakes" by Joseph Hallinan (honestly, one of the best human error books out there), the author recants the Heparin overdose story regarding Dennis and Kimberly Quaid's twins, and the use of heparin to clean out the IV lines (I am no medical whiz, but believe this process is called "lock-flush"). Without going into too much detail, the problem was mainly with the heparin dosage vials being of the same size, shape, and design, leading up to the last line of defense - the person administering the drug. In this case ten thousand units per milliliter instead of ten units per milliliter. Tragically, babies have died from this lock-flush mix-up, and in response one month before the Quaid twins were overdosed, the manufacturer of heparin changed the design of the dosage vials; however, they did not think it was important enough to pull the old ones off the shelf - you guessed it, the twins were overdosed with an older-style vial.
Show me some statistics
Death rate extrapolations for USA for Medication errors: 7,000 per year, 583 per month, 134 per week, 19 per day, 0 per hour, 0 per minute, 0 per second. Note: this extrapolation calculation uses the deaths statistic: estimated 7,000 deaths (Institute of Medicine report). Source link
26% of primary malpractice acts or omissions were medication related in the US 1990-96 (The National Practitioner Data Bank Public Use File) Source link
"Approximately one in every 400 hospitalizations is associated with a medication error that adversely impacts patient care," says Craig Svensson, dean of the College of Pharmacy, Nursing, and Health Sciences. Source link
More than 1.5 million Americans a year experience preventable drug-induced injuries, says a Purdue University health sciences expert. Source link
How do I talk to kids about prescriptions and medication?
Click here for "Knowing is half the battle"Click here for "Teaching Kids About Using Medicine Safely"Click here for "Expert Advice: Kids and Medicine Safety"Last video link for this post - This mother made a video of her daughters at a hospital - if you think your kids are safe around over-the-counter or prescribed medicine containers you need to watch this - the video quality is poor, but don't let that stop you - this is a great video, and if you are a parent, I promise that it will impact you.Wrap-up: As you can see by this post, there is a lot of video and media content available online to help inform you and speak with your family about medication. Take the action to do it and keep your family safe. We all need to take action when we know tragedy can be prevented.