Top 10 Fatal or Harmful Prescribing Errors.

By Alia Paavola, Becker’s Hospital Review. 

Below is a list of 10 top prescribing errors that cause death or severe harm to patients, as cited by, ‘The Pharmaceutical Journal’. 

  1. Drug prescriptions were omitted or delayed. An analysis of 64 prescribing incidents that were reported to the NHS National Reporting and Learning Service found that 37.5 percent of the incidents involved prescriptions that were forgotten or delayed. 
  1. Anticoagulants. Unsafe anticoagulant therapy, using oral warfarin, the newer direct-acting anticoagulants, injected heparin and low-molecular-weight heparins have all been reported in error incidents that have caused death and serious harm. 
  1. Unsafe opioid prescribing. In one case, more than 450 patients died after being prescribed opioid medications at Gosport War Memorial Hospital in England 
  1. Insulin prescribing. Almost one-third of inpatients with diabetes experienced a medication error during their hospital stay, according to NHS Digital. 
  1. Nonsteroidal anti-inflammatory drugs. These drugs are responsible for 30 percent of hospital admissions for adverse drug reactions, including bleeding, heart attack and kidney damage, according to the report. 
  1. Drugs that require regular blood test monitoring.Some drugs, like angiotensin-converting enzyme inhibitors, lithium and diuretics require regular blood testing. Often, if there is not regular monitoring of blood, these drugs can cause serious harm or even death. 
  1. Known allergy to medicine.Often, patients with known and documented allergies are exposed to a drug and suffer adverse events. 
  1. Drug interactions. Drug interactions can reduce efficacy or increase adverse effects. 
  1. Loading doses. Loading doses, when a prescriber initially gives a higher dose at the beginning before dropping down to a lower maintenance dose, is a big prescribing error because miscalculations can occur. 
  1. Oxygen. While not often described as a drug, the report claims that it should be treated as one. It is prescribed for hypoxaemic patients, and the administration of an inappropriate concentration of oxygen can have serious or even fatal consequences. 

Note: The journal used data from observational research, patient safety incident reports, yellow card reports and medical indemnity claims to determine the top 10 errors. 

Feb. 21, 2019

  

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