Medication Errors

THE SCOPE OF THE PROBLEM

Medication errors is one of the most stubborn and dangerous problems in American medicine today.

Studies by the Medical Profession and Drug Industry have reported the following facts: (1)

• Between 770,000 and 2 million patients in American hospitals are injured each year because of medication errors.
• 30% of hospital medication errors are serious; 12% are life threatening; 1% are fatal.
• In other words, as many as 20,000 Americans may be killed each year by medication errors in hospitals where they went to get better.
• Preventable medical errors, including medication errors, kill more Americans each year than motor vehicle accidents, breast cancer, or AIDS

When medication errors occur, the result can be catastrophic. (2)

• A 2001 study in the American Jounral of Health-System Pharmacists, illustrated the potentially devastating results of a medication error:
• Of 5,366 medication errors reported during a 5-year period:
• 3,660 (68.2%) were classified as serious under federal regulations (causing a threat to life, hospitalization, disability, congenital abnormality, or requiring treatment to prevent permanent impairment)
• 469 (8.8%) of the patients died because of the medication errors

Children are especially vulnerable to medication errors.

• Children are smaller and weigh less and can be immediately harmed by a medication error
• Many medications are shipped from the drug manufacturer, only in adult strength doses, making dilution errors an ever-present danger to children
• Infants and very young children cannot tell anyone if they are feeling poorly after a medication error
• Medication errors to children have been known to cause seizures, breathing problems, coma, and even death.

Anesthesia errors can be deadly

• The anesthesia profession has led the way in attempting to minimize medication errors
• When anesthesia errors do occur, they are more likely to be very serious or deadly
• Some of the more serious types of anesthesia errors include, failing to properly monitor the patients oxygenation, failing to adequately empty the stomach, causing the patient to vomit into their lungs, use of the wrong type of anesthesia, improper intubation, premature extubation – all can cause brain injury or death

THE CAUSES OF MEDICATION ERRORS

While there are many causes of medication errors, certain factors have been identified as particular problem areas:

• Poor labeling of drugs
• Dilution errors, especially for children
• Drugs that sound alike, leading to the dispensing of the wrong drug
• Illegible handwriting by doctors, causing the wrong drug to be given
• Injections of medications intended to be taken orally
• Addition of a zero to intended prescription strength (for ex., 12mL read as 120 mL)
• Wrong tube connected; oxygen or saline solution pumped into patient rather than the intended IV medication
• Failure or absence of communication between health care professionals in a hospital

WHAT CAN BE DONE ABOUT THE PROBLEM?

The medical profession is taking the medication error problem seriously, though much improvement is still needed.

• Most medication errors are the result of a breakdown in systems leading to a “cascade of errors” – every link in the chain from receipt of a drug into a hospital pharmacy, to administration of the medicine to the patient, must be evaluated and re-evaluated for safety
• The concept of “redundancy” that is integral to the airline industry, must be incorporated into the administration of medication, meaning that if one part of the system fails, another will pick up the error before it harms the patient
• Better training, especially of pharmacy technicians, many of whom earn between $8.00 - $10.00 per hour, is essential
• Doctors must avoid the use of abbreviations when prescribing medications, as that increases the chance that the wrong drug, with a similar abbreviation, will be prescribed
• More effort must be had from the pharmaceutical industry, to improve labeling, to sell more drugs in individual dose vials, to manufacture more drugs in pediatric strength, to avoid giving drugs similar names
  

YOUR LEGAL RIGHTS

WHAT TO DO IF YOU SUSPECT THAT YOU OR A LOVED ONE HAVE BEEN HARMED BY A MEDICATION ERROR

How do you know if you have been harmed by a medication error?

• Although hospitals are required by law to report all medication errors, they do not always comply
• Even if the hospital reports the medication error, as required by law, the report is completely confidential – the patient does not receive the report and is not even told it has been filed
• Unfortunately, a patient or his or her parent or spouse, may never be told that their injuries were caused by a medication error, even if the hospital knows about it and has filed a confidential report

What steps should I take to protect my legal rights?

• The most important step you can take is to contact an attorney right away if you or a loved one has suffered unexpected serious injury in a hospital, even if you are unsure of the cause
• If a medication error occurred, the evidence will usually be found on doctors’ order sheets, medication logs, or anesthesia charts, not obvious to most patients
• The sooner medical records can be obtained and analyzed, the less the chance that vital records will be “lost” by the hospital, or altered – although it is illegal, destruction and altering of medical records to cover up medical negligence, does occur

What are my legal rights if I or a loved one has been harmed by a medication error?

• Medication errors are a form of medical malpractice or professional negligence
• In order to recover money damages because of a medication error, you must be able to prove 3 elements:

1. the health care professional(s) who were negligent owed you a duty to exercise reasonable care – this is usually easy to prove
2. the health care professional(s) were negligent in their treatment, meaning that they did not perform in accordance with “acceptable standards” of medical or pharmacological practice
3. the negligence caused injury

• The amount of money that you may recover will be affected by a number of factors, including the severity of the negligence (would it be shocking to most people?), the health of the person before the negligence, the strength of any defense, the severity and permanence of the injuries
• In Massachusetts, the right to bring a medical malpractice or professional negligence case, may be lost forever, usually within 3 years after the negligence occurred or should have been discovered by the patient (the rules are somewhat different for minors)
• The best advice is to seek legal counsel immediately if you or a loved one have suffered unexpected harm in a hospital or due to medical care

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  (1) Institute of Medicine, “To err is human: building a safer health care system,” Wash., D.C., National Academy Press, 1999; Brennan, TA, et al., “Incidence of adverse events and negligence in hospitalized patients,”N Engl J Med 1991; 324: 370-6; Leape LL, et al., “The nature of adverse events in hospitalized patients,” N Engl J Med 1991; 324-84.
  (2) Phillips J, et al., Retrospective analysis of mortalities associated with medication errors,” Am J Health-Syst Pharm, Vol 58, Oct 1, 2001.