Need for implementation of safe medication practice to avoid medication errors – A journey through case series

ABSTRACT

Patient safety is seriously threatened by medication errors. Pharmacological therapy aims to accomplish particular therapeutic objectives that improve patient quality of life while reducing patient risk. To develop a clear plan for minimizing medication errors and establishing safe and effective medication practices, the study’s major goal is to identify the key locations at which medication errors usually occur. The five scenarios presented here demonstrate the frequent errors that took place, including communication problems, technical errors, rule-based errors, and knowledge-based errors. Patients’ quality of life must be improved by educating both patients and healthcare workers on safe medication practices. This involves monitoring for and recognizing errors, reporting them in a blame-free environment, analyzing their root causes, changing procedures on the lessons learned, and ongoing monitoring.

Introduction

Anywhere in the healthcare system, from the prescriber to the dispenser to administration to patient use, medication errors can occur. But the truth is that many errors may be prevented.[1] Medication errors pose a serious threat to patient safety. The achievement of specific therapeutic outcomes that enhance patient quality of life, while lowering patient risk is the aim of pharmacological therapy.[2] Incorrect prescribing, which accounts for more than half of all preventable hospital pharmaceutical errors, is probably the most frequent cause of avoidable occurrences. Other contributing causes include defective supply, labeling, and administration problems.[3]

A medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention.[1]

In hospitals, medication errors are a common issue. According to studies, adverse drug reactions (ADRs) and medication errors are two of the major causes of hospital adverse events that result in disability and death in up to 6.5% of hospital admissions.[4]

Illegible orders, lack of patient information, insufficient medical knowledge, an increase in patient load, inability to monitor drug concentration or drug therapy, and failure to take into account changes in renal and cardiac function are a few of the factors linked to medication errors.[5]

There have been numerous studies on medication error rates in hospitals around the world; however, low- and middle-income countries have not had enough research done on them despite having higher medication usage rates.[6,7] Therefore, the purpose of the study is to determine the main points at which medication errors frequently occur to create a clear strategy for preventing them and implementing safe and effective medication practices.

Case Reports

Case 1

A 19-year-old female patient arrived in the emergency room with a headache, malaise, and the abrupt onset of ptosis. According to history, she was sleeping outside the room because it was a hot, humid night. She complained of ptosis, a rapid start of speech trouble, in the early morning. There was no other chronic disease history or pertinent drug administration history. After a thorough examination, it was revealed that her left foot had very minor bite marks. The doctor determined it to be a case of a neurotoxic snake bite and administered anti-snake venom, neostigmine, and atropine as treatment. The patient began to have blurred vision on the third day. The treating physician was able to identify the medication error and determine the reason for the impaired vision. He was surprised to see that the nurse’s bedside chart showed that atropine had continued despite the injection of neostigmine being halted when he checked the records out of curiosity. After realizing the error, the doctor immediately stopped atropine and administered pilocarpine drops in both eyes. Within a few hours, the patient regained her vision.

Case 2

A 43-year-old male patient was brought into the medical ward complaining of a fever, increased frequency, and burning sensation during urination. He had neither hypertension nor diabetes. The primary care doctor made the clinical diagnosis of a urinary tract infection. He prescribed injections of gentamicin and ampicillin after sending the urine for routine testing and a culture and sensitivity report. The patient’s health worsened on the fourth day of therapy despite improvement. On that day, the doctor suggested performing a standard urine test, and the results revealed the presence of sugar that had not been there previously. The blood was next sent for a sugar assessment, and this time hyperglycemia was found. The doctor was perplexed and looked through the patient’s bedside record of medications to determine the cause. Moreover, nothing unusual was found. He checked the injection ampoules after that and was shocked to see that the patient was receiving injectable dexamethasone rather than gentamicin. After the correction of the mistake, the patient gradually improved.

Case 3

A 36-year-old male patient was brought into the medical ward complaining of acute, severe pain involving the right first metatarsophalangeal joint, coupled with joint swelling and redness, and fever that had been present for approximately six hours. He had a history of hypertension and was now on antihypertensive medication. He had experienced a similar episode two years prior, though the pain was less intense. Upon further inquiry, it was revealed that he had just changed his antihypertensive medication, which contained both telmisartan and hydrochlorothiazide and had been prescribed by his primary care physician. Hyperuricemia is a well-known side effect of hydrochlorothiazide. The prescribing physician substituted a suitable medication for hydrochlorothiazide. He eventually got better after receiving analgesics for the initial episode.

Case 4

A 34-year-old female patient with primary infertility, weakness, and body aches visited the medical outpatient department. She had hypothyroidism and was obese (body weight of 71 kg). Nine years ago, her treating physician gave her a prescription for levothyroxine (112.5 μg), and she was already taking it. Her TSH level is still high and her free T4 level is low after additional laboratory testing. When the current doctor checked the medications, he was startled to find that the patient was only taking 12.5 μg of levothyroxine instead of the 112.5 mg that had been recommended. Following that, he explained the error to the patient, who later recovered.

Case 5

A 29-year-old male patient was brought into the medical ward with complaints of respiratory distress, fever, and body aches. Right-sided pleural effusion was identified following a regular blood test and chest x-ray. For an etiological diagnosis, the treating doctor intended to aspirate the pleural fluid. He requested a pleural fluid aspiration set with a local anesthetic injection (lignocaine injection) from the on-call nurse. After that, the physician injected lignocaine into the location of the pleural aspiration. However, the aspiration area was not anesthetized after a brief interval. When the doctor evaluated the injection, he was shocked to discover that it was sodium stibogluconate and not lignocaine.

Discussion

If we evaluate the situations, we can see that in the first three instances, the patient’s quality of life was impaired and their hospital stays as well as their sufferings were prolonged. In the fourth instance, the patient had to endure more suffering for a longer period, which negatively impacted his health. In the fifth one, the patient did not get the right medication, so he experienced extra pain and hazards due to improper medication.

We classified the severity of the medication errors using the NCCMERP index tool [Figure 1] to better understand the health risks to the patients listed above [Table 1].

Figure 1.

National Coordinating Council for Medication Error Reporting and Prevention’s index for categorizing medication errors[8]

Table 1.

Severity of the medication errors[8]

Case	Severity category	Description
1	Category E	Category E: This category includes an error that may contribute to or result in temporary harm. These errors may require intervention to prevent them
2	Category F	Category F: An error occurs that may contribute to or result in temporary harm and require initial or prolonged hospitalization of the patient
3	Category F	Category F: An error occurs that may contribute to or result in temporary harm and require initial or prolonged hospitalization of the patient
4	Category D	Category D: An error occurs that reaches the patient and needs monitoring to confirm that the error causes no harm to the patient. This error also requires intervention to prevent harm
5	Category C	Category C: An error occurs and reaches the patient but does not cause any harm to the patient

The five cases described here show the common errors occurred in the healthcare system. We have analyzed the type of errors in the above-mentioned cases, which is depicted in Table 2.

Table 2.

Type of medication errors that occurred in these cases

Case	Errors occurred
1	• Communication error • Technical error • Rule-based error
2	• Rule-based error • Technical error
3	• Knowledge-based error • Communication error
4	• Communication error • Technical error
5	• Technical error • Rule-based error • Communication error

In four out of five situations, it has been found that there have been technical and communication failures. Three examples of rule-based error and one incident of knowledge-based error are recognized.

Knowledge-based errors: Knowledge-based errors can be related to any type of knowledge, general, specific, or expert. As it is known that the hydrochlorothiazide group of drugs can cause hyperuricemia, it can also aggravate the pain in the patient suffering from gout as observed in case 3.

Rule-based errors: Rule-based errors can further be classified as either the misapplication of a good rule (e.g., injecting dexamethasone instead of gentamicin in case 2 and providing sodium stibogluconate instead of lignocaine during the procedure in case 5) or the application of a bad rule or the failure to apply a good rule (e.g., continuation of atropine causes atropine overdose in case 1).

Technical errors: Technical errors form a subset of action-based errors. They have been defined as occurring when “an outcome fails to occur or the wrong outcome is produced because the execution of action was imperfect.”[9] Healthcare professionals did not follow the instructions properly about omitting atropine and neostigmine in case 1, administration of dexamethasone instead of gentamicin in case 2, providing 12.5 microgram of levothyroxine tablet instead of 112.5 microgram tablet without properly checking the prescription in case 4, and providing sodium stibogluconate instead of lignocaine without properly checking the label in case 5.

Poor patient outcomes, resource waste, reduced quality of service, and excessive healthcare expenses are the main repercussions of communication errors in the medical field. Failures in communication can have a detrimental impact on staff and patient satisfaction. Here, the communication error occurs due to a lack of communication between the healthcare professionals (HCP) in cases 1 and 5, the HCPs and the pharmacist in case 4, and the HCPs and the patients in case 3. Table 3 provides a list of the many errors identified in these situations and the appropriate corrective measures.

Table 3.

Table 3 provides a list of the many mistakes identified in these situations and the appropriate correction measures[9]

Errors	Corrective measures
Communication error	• Communication skill programs conducted by health care professionals (HCP)
	• Enhancing communication about work processes
	• Verbal communication about digital prescriptions between professionals
	• Encouraging patients to communicate about medication[10]
Technical error	• Improving proper skills and techniques during the learning program of HCP.
	• Training can help in preventing technical (action-based) errors
Rule-based error	• Computerized decision-support systems can also train prescribers to make fewer errors
Knowledge-based error	• Improving knowledge, e.g., by ensuring that students are taught the basic principles of therapeutics and tested on their practical application and that prescribers are kept up to date

There are many ways to improve medication safety in hospitals. One way is to develop and implement a medication safety program. This program should include a system for tracking and reporting medication errors and a process for investigating and responding to errors. Additionally, hospitals should educate staff on medication safety and provide resources for staff to use when dispensing and administering medications.

Conclusions

There are numerous causes of medication errors in addition to numerous preventative measures. However, we must commence by acknowledging that mistakes can happen but must take precautions to reduce the dangers and sufferings of the patients. Monitoring for and recognizing errors, reporting them in a blame-free atmosphere, with shared responsibilities, analyzing their core causes, altering procedures by the lessons learned, and continued monitoring are critical parts of imparting safe medication practice to improve the quality of life of the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.