Preventing Medication and Medical Device Errors

Adverse drug events (ADEs) result in more than 770,000 injuries and deaths each year and cost up to $5.6 million per hospital, depending on size. Patient injuries that result from prescribed drugs are among the most common patient safety errors. The outcomes of these events can range from a rash that clears up quickly to a patient death.

On the national level, a number of organizations and agencies have been working to decrease medication errors.

In addition to adopting the recommendations from The Joint Commission about certain abbreviations that should not be used when prescribing, the Institute for Healthcare Improvement has several guides for patient safety in general, and for preventing adverse drug events as well as preventing harm from high-alert medications. They also have available (free) on their website a paper titled, “Respectful Management of Serious Clinical Adverse Events”. The Institute for Safe Medication Practices (ISMP), based in suburban Philadelphia, is the nation’s only 501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use. They provide resources that can be used for “impartial, timely, and accurate medication information.”

Adverse events are those with undesirable effects for patients resulting from any medical product. These must be reported to the Food and Drug Administration if:

• A patient’s death is suspected of being the result of the adverse event.
• A patient was at a substantial risk of dying at the time of the adverse event or it is suspected that the use or continued use of the product would result in the patient's death.
• Admission to a hospital or a hospital stay is prolonged as a result of the adverse event.
• The adverse event resulted in a significant, persistent, or permanent change, impairment, damage or disruption in the patient's body function/structure, physical activities or quality of life.
• There are suspicions that exposure to a medical product prior to conception or during pregnancy resulted in an adverse outcome in the child.
• You suspect that the use of a medical product may result in a condition which required medical or surgical intervention to preclude permanent impairment or damage to a patient.