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Errors in medication management are in 2020's top 10 list of most common sentinel/never events

Nursing, physician, pharmacy medication errors can cause patient harm

The Joint Commission, the nation’s oldest healthcare accrediting organization, recently announced that errors in medication management was in the top 10 list of sentinel events in 2020.

Sentinel events are also called never events because they’re considered to be avoidable with proper policies, procedures, and staff training. When they occur, hospitals leaders must conduct a root cause analysis to find out what system and personnel failures led to the sentinel event, and what changes can be made to avoid them from harming future patients.

Medication management errors come in many shapes and sizes. Here are some of them.

High-alert medications

The Institute for Safe Medicine Practices identified high-alert medications that have the highest risk of injury or death when misused. The top 5 medications on the list include:

• Insulin

• Opiates and narcotics

• Injectable potassium chloride or phosphate concentrate

• Intravenous (IV) anticoagulants (heparin)

• Sodium chloride solutions above 0.9% (hypertonic saline)

Hospitals should have robust pharmacy and clinical policies, procedures, and training in place to make sure that these high-alert medications aren’t misused in a way that endangers patients. The Joint Commission recommends some simple safety steps to avoid errors, including:

• Dosage check systems: Ensure that the order contains the correct dosage for a specific patient.

• Storing high-alert medications away from each other to avoid mix ups.

• Avoiding abbreviations on orders and labelling, which can lead to drug mix ups and dosage errors.

• Have an independent double-check procedure for programming into infusion pumps. We represented the family of a Tomball, Texas patient in a wrongful death medical malpractice lawsuit. He died after a nurse made an error on the infusion pump for his pain medication, leading to an overdose of 10,000 times the correct dosage.

Medication errors

We’ve handled all kinds of cases involving simple medication errors—by simple, I mean they could easily be avoided with closer attention. Last year, we resolved a case against one of the major national pharmacy chains for filling and dispensing a prescription medication that partially contained the wrong pills. This caused the patient to experience an episode of hypotension (low blood pressure) and other symptoms, requiring an emergency trip to the hospital.

Other simple medication errors occur when the doctor or prescriber orders a correct medication with the wrong dosage. Additional pharmacy errors involve receipt of a proper prescription but filling it with the wrong medication or dosage.

Medication reconciliation

The standard of care requires the nursing staff to collect a complete list of patient home prescription and over-the-counter medications, and documenting it in the patient chart, for each office visit or hospital admission. It’s up to the nursing staff to ask for this important information.

It’s up to the patient to provide accurate information.

It’s up to physicians and other providers are required to review the list.

The idea behind medication reconciliation is avoiding medication errors. Some medications can’t be given in overlapping periods with other drugs or supplements, or when a patient has certain pre-existing conditions. Sometimes these warnings can be overridden with deliberate clinical judgment of a physician or prescriber that the benefits outweigh the risks. Other times, though there’s a manufacturer’s contraindication, meaning that the drugs absolutely can’t be used during certain circumstances.

Medication reconciliation errors occur when:

• A nurse doesn’t ask for a medication list, and the doctor or prescriber doesn’t follow-up.

• The patient provides an incomplete list.

• A pharmacy fills and dispenses a drug when its records reflect a warning for the patient and doesn’t question the physician or prescriber.

• A pharmacy fills and dispenses a drug when its records reflect a contraindication for a patient.

If you’ve been seriously injured because of a medication error in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for a free consultation about your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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