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Dangerous Errors in Medication Management

By October 29, 2021November 29th, 2021Blog, Medical & Hospital Malpractice
medication management

When a physician discontinues a medication’s use and the medical team is not aware, patients can be harmed.

That’s the experience of a Utah-based healthcare organization that took a closer look into how serious medication errors happen.

Types of Medication Errors

An estimated 7,000 to 9,000 U.S. patients die every year from medication errors, which are preventable (“Medication Dispensing Errors And Prevention,” 2021).  Medication errors typically involve:

·         Giving the wrong medication to a patient

·         Giving medication to the wrong patient

·         Giving the medication in the wrong dose to a patient

·         Giving the medication to the patient via the wrong route

·         Giving the medication to the patient at the wrong time

Multiple healthcare professionals typically are involved in the drug administration process – the doctor who prescribes a medication, the pharmacist who fills the prescription, and the provider who administers the medicine. With so many people involved, a drug error may have multiple causes.

But even if the original drug administration process is successful, subsequent medication mistakes may occur.  That’s the issue the Utah healthcare researchers examined.

Patients Given Discontinued Medications

Intermountain Healthcare discovered a significant problem with discontinued medications: often a doctor ordered a medication dropped from a patient’s record but the order was not implemented. Intermountain had a number of patients who continued taking discontinued medication, and they required hospitalization.

So the researchers wanted to determine why this happened and how to avoid future discontinued medication errors and the resulting patient harm.

The majority of the prescriptions sent to community pharmacies, which included national chains and local stores, were transmitted electronically.  Revised medication orders likewise were sent electronically to the pharmacies.

But frequently the pharmacies didn’t get or see these new medication orders.

The researchers first looked inward.  The electronic prescription ordering system included a way to alert pharmacies about any changes.  But some of the pharmacies weren’t recording these updates, either because their systems weren’t compatible, or because they were simply overlooked.

To correct this, nurses and pharmacists called pharmacies and alerted them to a patient’s change in medication or a change in dosage.

They also utilized a previously ignored feature of their electronic health record system that notifies a pharmacy when a medication is dropped, just as it would when sending in a new prescription.

In two months, the renewed communication efforts of personal phone calls and electronic alerts to community pharmacies found and prevented nearly 200 potential medication errors involving discontinued medications.

This is another example of how important clear and complete communications are to avoiding preventable medical errors.  Miscommunications in the drug administration process or during other medical treatment have been catastrophic for many patients.

If you believe you or a loved one was the victim of a serious medical error, contact a medical malpractice attorney about investigating further to hold all responsible parties accountable.

The choice of a lawyer is an important decision that should not be based solely on advertisements.

Authored by Gray Ritter Graham, posted in Blog October 29, 2021