Much has been written lately in both the professional and lay press about medical errors, particularly medication errors. One group reported that 1.5 million Americans are injured each year because of preventable prescription medication errors. Of these, 7,000 Americans die as a result of these errors.1 Similar statistics were reported by the President's Advisory Commission in Consumer Protection and Quality in the Health Care Industry.2 "An average of one medication error occurs per patient per day."2(p620) This results in approximately 400,000 errors occurring in the hospital setting and 1.1 million errors occurring in other settings.2
Clearly, prevention of medication errors is a top priority for all healthcare providers including critical care nurses. Although we work diligently to prevent medication errors, we must also make certain that we are not the victim of such errors.
I have been the victim of 4 medication errors over the past 30 years. The first occurred in an emergency department (ED) after a minor car accident. I just hit my head so it was not a serious injury. There was more damage to the steering wheel than to my head (in the era before airbags). I had informed both the ED nurse and physicians that I have an allergy to aspirin. This was noted in red letters on the front of my chart. The physician ordered a non-narcotic for relief of pain. I was unfamiliar with the medication and asked the physician if it contained aspirin. I was assured it did not. I had the prescription filled and then went home. Fortunately, I checked several reference books before taking the medication, and much to my dismay, the main ingredient was aspirin. I did not take the medication and called my private physician. I also informed the ED of the error by letter (copy furnished to the administration). I never received a response. If I had taken the medication, I would have developed bronchospasm, which would have required a repeat visit to the ED.
The second medication error also involved aspirin. I was hospitalized after abdominal surgery. The day after the surgery, I was visited by a physician in the same practice as the one who performed my surgery. She discontinued the patient-controlled analgesia pump, which was fine with me. However, she then informed that me she would order Percodan (aspirin and oxycodone). I told her Percodan has aspirin in it. We argued for a few minutes until she said I should listen to the doctor and take the Percodan. It was either Percodan or nothing. She left the room. I requested pain medication a few hours later, and the nurse brought Percodan to the room. I again informed the nurse of my allergy to aspirin. The nurse then proceeded to tell me that since the doctor ordered it, the medication was fine to take. I asked the nurse to take the Percodan away and check her drug reference books. I remained in pain until the next morning (this was after the same discussion with 2 more nurses) when my physician arrived demanding to know why I refused Percodan. He and I also argued for a few minutes about aspirin as an ingredient in Percodan. He finally surrendered and asked if I would take acetaminophen with codeine. I agreed, but I was still fuming. A few minutes later, he entered the room looking very contrite. He had checked the drug reference book and realized he was wrong. He apologized for the actions of himself and his colleague. Still, there was no reason I should have not received pain medication the day after surgery. Even the nurses (whom I know) did not intervene on my behalf.
The third incident involved a pharmacy at a well-known chain. I picked up my prescription and brought it home. When I read the label, I noticed the medication was for erectile dysfunction (I am a female). The prescription had the correct patient name and physician name, but the bottle contained the wrong medication. I immediately returned the pharmacy and asked to speak with the pharmacist who filled the prescription. Well, after telling her the problem, she was laughing too hard to do anything about it. She even called her colleagues over to see what she had done. What if I had been a patient who just remembered that the doctor said I should take the medication once a day and did not read the label? As we all know, there are many patients who do this. I filed a complaint with the pharmacy chain and the state board of pharmacy. I never heard from either of them.
The fourth medication error occurred at another well-known pharmacy chain. I asked for my prescription, and the technician gave me someone else's medication. The last names were similar but not identical. I caught this error before I left the counter.
All of these errors were due to (1) not listening to the patient, (2) healthcare providers' unwillingness to check drug references, (3) lack of patient advocacy by some nurses, (4) inattention to detail, and/or (5) apathy. All of these errors could have had serious implications had I taken the medication. In addition, all of these errors could have been prevented if everyone followed the rules for administration of medication: right patient, right medication, right dose, right time, and right route.2
All of us are responsible for our actions and must be constantly aware of the potential for medication errors. Then we must take steps to develop and implement strategies to prevent these errors. Mistakes will happen. We are human. But we can work together-nurse, physician, patient, and pharmacist-to lessen the frequency of medication errors. On a personal note, remember you may be the victim of a medication error someday. Check all of your prescriptions carefully.
Vickie A. Miracle, EdD, RN, CCRN, CCNS, CCRC
Editor, DCCN and Lecturer
Bellarmine University
School of Nursing
Louisville, KY
[email protected]
References