Tackling Medication Errors with Pharmacovigilance

Medication errors pose a significant challenge within global healthcare systems. These errors, which can occur at any stage of the medication process, from prescription to administration, have serious implications for patients. Imagine administering medication to the wrong patient, prescribing the incorrect dosage, overlooking necessary medications, or mistakenly entering orders. This article explores the types of medication errors, the role of pharmacovigilance in mitigating these errors, and strategies to enhance patient safety.

Understanding Medication Errors

Across the world, people take medicines to prevent diseases and improve their health conditions. Unfortunately, unsafe medicines, medical practices, and medication errors are leading causes of injury and avoidable harm in healthcare systems worldwide. Globally, medication-related harm accounts for 50% of preventable harm in medical care and is estimated to cost USD 42 billion in global health expenditure, according to the World Health Organization (WHO). These errors typically involve administering the wrong drug or dose, using the wrong route, administering it incorrectly, or giving medication to the wrong patient.

Estimating the Cost of Medication Errors

A medication error (ME) is an error in the medication treatment process that may occur during all stages of medication use, from ordering to dispensing and administration to monitoring. MEs constitute a significant challenge to patient safety and are associated with patient harm and increasing national expenses. The prevalence of preventable medication harm has been estimated to be 3% in adult patients in primary and secondary healthcare settings on average, with higher rates in elderly (11%) and intensive care patients (7%). For example, in the UK, error-related harm is estimated to contribute to more than 1700 deaths per year, costing £98.5 million (€114.6 million) for hospital admissions and extended hospital stays. In European healthcare, the estimated yearly cost ranges from €4.5 to €21.8 billion; worldwide, it adds up to about €35 billion.

Types of Medication Errors

Medication errors can occur at any stage of the medication process – prescribing, dispensing, administering, or monitoring. These errors can result from human mistakes, system failures, and communication breakdowns. Common types of medication errors include:

Prescribing Errors

These involve incorrect drug selection, dosage mistakes, or prescribing drugs that may interact negatively with other medications the patient is taking.

Dispensing Errors

Mistakes made by pharmacists, such as giving the wrong drug, incorrect dosage, or mislabeling medications.

Administration Errors

Errors occur during medication delivery to patients, such as incorrect timing, wrong route of administration, or giving medication to the wrong patient.

Monitoring Errors

Failures in properly observing the patient’s response to medication and making necessary adjustments to the treatment.

Case Study from Medical Literature

A noteworthy case published in medical literature and identified by DrugCard underscores the importance of understanding medication errors. A 74-year-old woman had ovarian cancer return, so doctors considered another surgery. Before the surgery, she got pain relief through an epidural along with general anesthesia. After the surgery, she controlled her pain using patient-controlled epidural analgesia with ropivacaine-epinephrine. However, on the first night after surgery, she felt abdominal pain. The next day, a nurse discovered that the pump had ciprofloxacin instead of the expected medicine. An investigation found that both drugs were stored together, but the ciprofloxacin was in a box. The nurse didn’t realize this and used the wrong one. The medical team informed the patient of the error and did not report any symptoms except the reappearance of pain. Three days later, she went home without any other issues.

Preventive Measures for Medication Errors

Routine risk-minimization measures to prevent medication errors that national competent authorities and the European Medicines Agency (EMA) apply include ensuring that:

• The proposed name of medicine does not sound similar to the name of another medicine;
• The labelling of medicine does not look similar to the labelling of other medicines;
• The instructions in the product information on the medicine use are straightforward so as not to lead to medication errors.

When the risk of medication errors is high and routine measures are deemed insufficient, stakeholders implement additional measures to ensure the correct use of medicine. These measures encompass educational programs for healthcare professionals and patients.

Mitigating Risks of Look-Alike and Sound-Alike Medicinal Products

Potentially similar-looking or similar-sounding medicinal products, known as look-alikes and sound-alikes (LASA), also present a further risk. The name of a medicinal product is a major identifying and distinguishing feature. Therefore, mix-ups because of too similar designations must be ruled out, regardless of the respective visual appearance. (Invented) names or additions with descriptive content should reflect the properties of a medicinal product and should not suggest false notions regarding indication or site and route of administration. The packaging design should also help prevent misuse due to confusion, ambiguity, or trivialization.

Conclusion

Medication errors represent a serious issue in healthcare systems worldwide. These errors, which can occur at any stage of the medication process, have serious implications for patients. Reliable measures to prevent errors and increase awareness among healthcare professionals and patients must be noticed. Pharmacovigilance is crucial in reducing the risks associated with medication errors and ensures patient safety, a primary goal of all healthcare systems.