Some Lessons Learned From A "Top 10" Drug Errors Session At The American Pharmacists Association 2007 Annual Meeting
(Posted by Tom Lamb at DrugInjuryWatch.com)
The American Pharmacists Association (APhA) Annual Meeting was held in Atlanta, Georgia earlier this year. A large number of the 7000 attendees took time out of their busy schedules for one of the meeting's most popular sessions, "The Top 10 Adverse Drug Reactions and Medication Errors", which was presented by Matthew Grissinger, RPh, FASCP, a medication safety analyst with the Institute for Safe Medication Practices (ISMP).
As reported in a Medscape.com article by Kathryn L. Hahn, PharmD:
Grissinger first referred to a study that identified the 10 drugs most commonly implicated in adverse events requiring treatment in a hospital emergency department (ED). The study also documented the frequency with which each of the 10 drugs was involved:
1. Insulin (8%);
2. Anticoagulants (6.2%);
3. Amoxicillin (s) (4.3%);
4. Aspirin (2.5%);
5. Trimethoprim-sulfamethoxazole (2.2%);
6. Hydrocodone/acetaminophen (2.2%);
7. Ibuprofen (2.1%);
8. Acetaminophen (1.8%);
9. Cephalexin (1.6%); and
10. Penicillin (1.3%).
According to this May 2007 Medscape.com article, Dr. Grissinger said approximately 40% of these adverse drug events that required a patient to be treated at a hospital emergency room involved unintentional overdoses.
More generally, so-called "nonadherence issues" were the usual cause for adverse drug events that led to a trip to the hospital; among them were:
- taking incorrect doses;
- taking doses at the wrong times;
- forgetting to take doses; and,
- stopping the medication too soon.
Dr. Grissinger's presentation at the APhA 2007 Annual Meeting also covered the top 10 medications most frequently involved in drug errors. By definition, drug errors are unintentional acts committed by healthcare providers involving medications.
As many have heard by now, in 1999 the Institute of Medicine (IOM) published a report, "To Err Is Human: Building a Safer Health System", which included their finding that as many as 7000 Americans die from medication errors each year.
From the 2007 Medscape.com article, this is what was learned about medication errors at the Grissinger session:
A somewhat different top 10 list identifies medications that are most commonly misused or mishandled in some way by healthcare professionals. This list is based on information from the United States Pharmacopoeia (USP), which maintains a database of medication errors that are reported anonymously. The figures represent drug errors associated with acute hospital care:
1. Insulin (4% of all medication errors in 2005);
2. Morphine (2.3%);
3. Potassium chloride (2.2%);
4. Albuterol (1.8%);
5. Heparin (1.7%);
6. Vancomycin (1.6%);
7. Cefazolin (1.6%);
8. Acetaminophen (1.6%);
9. Warfarin (1.4%); and
10. Furosemide (1.4%).
Patients who have experienced an adverse drug reaction or a medication error requiring hospital treatment can submit a confidential report to the USP-ISMP Medication Errors Reporting Program (MERP), a voluntary program which is operated by the U.S. Pharmacopeia (USP) in cooperation with the Institute for Safe Medication Practices (ISMP).