ADVANCED PHARMACOLOGY UNIT 2 TEST 1 | COMPLETE
SOLUTIONS | 100% VERIFIED
Medical Errors Statistics/Prevalence - Third leading cause of death in the U.S.
More than 250,000 people die each year from medical mistakes
400,000 drug-related injuries occur in hospitals and 800,000 in long-term care settings
each year
Medication errors injury approximately 1.3 billion people annually
Medical errors cost the nation 1 trillion each year
Not all errors are reported
Medical Errors Consequences - Medical penalizes hospitals for safety incidents
Medicaid to cease reimbursement to hospitals for "never events" and avoidable errors
Computerized systems still miss major drug errors
Wrong dose, wrong drug, bad combinations, bad reactions
medication error long definition - any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control of the
health care professional, patient or consumer. Such events may be related to
professional practice, health care products, procedures and systems, including
prescribing, order communications, product labeling, packaging and nomenclature,
compounding, dispensing, distribution, administration, education, monitoring, and use
medication errors by stage of the medication process - Administration of improper dose
of medicine accounts for 41% of fatal medication errors
Administration of the wrong drug accounts for 16% of fatal medication errors
using the wrong route of administration accounts for 16% of fatal medication errors
Medication Errors causes - poor communication
poor handwriting
ambiguous directions
medical abbreviations
poor procedures : trailing zeroes
lack of knowledge
similar labeling/packaging : external warning labels
name confusion (lamisal vs lamictal; oxycodone vs oxycontin)
Pt misunderstanding
Pt misunderstanding medication error - a 19 year old female was prescribed
spermicidal jelly... four days after using the medication, the patient called her physician
complaining of severe stomach cramps and nausea. It was found that the patient was
spreading the jelly on her toast every morning.
, Name confusion - A verbal order from a physician for Lamictal was mistaken as
Lamisal (anti-fungal) for a patient with epilepsy .Fortunately, there was no adverse
event as the error was caught when the pharmacist was counseling the patient
regarding the drug's indication.
A physician wrote for Oxycodone (immediate release) 10 mg q4h prn pain but the nurse
pulled Oxycontin (sustained release) 10 mg tablets and administered this to the patient.
When attempting to reorder more, it was revealed that the patient had been given the
wrong medication
Similar labeling/Packaging - A patient was ordered esmolol for supra-ventricular
tachycardia and was ordered a bolus followed by a continuous infusion. The nurse
inadvertently used the concentrate (which requires dilution prior to use) rather than the
single-dose vial to administer the loading dose. The patient went into complete heart
block and died. The use of external warning label may have prevented this error.
A patient was ordered hydralazine 10 mg IV q6h (patient with a h/o advanced heart
failure).. the pharmacist inadvertently dispensed verapamil 5 mg/2ml vials because the
manufacturers vials are identical in color, size, and labeling.. the nurse administered
verapamil 5mg q6h x 3 doses before this errors was realized. pt's bp dropped to 80/60,
HR dropped to 42 and tele: heart block
lack of knowledge - a 26 y.o f pt, s/p delivery of her first chld was ordered an epidural of
fentanyl plus bupivacaine for pain. The pharmacist, recently licensed, prepared this
order with NS solution containing a preservative. As a result of her lack of experience,
the pt seized. this error lengthened her stay 3 days and resulted in a lawsuit
An orthopedic surgeon wrote for Demerol 75 mg IV q3h postoperatively for a 88 year
old male w/ a hx of renal impairment. 2 days after surgery this patient experienced a
grand-mal seizure and suffered stroke. This lack of knowledge caused an extended
hospital stay as well as a lawsuit
Poor procedures - A physician wrote an order for warfarin 1.0 mg qd for an 82 y.o
male... the dose was transcribed to the MAR as 10 mg daily and the dose was
administered to the patient... 3 days late the INR was >5, H/H dropped to 7.6/30 and the
patient had blood in his urine. The practice of having the charge RN double check the
transcription process would have avoided this error
Medical Abbreviations - 5 ASA tid. This order for mesalamine (5 aminiosalicylic acid)
was mistakenly read as 5 aspirin tablets 3 times a day. luckily the pt asked the
physician why she was taking that much aspirin (after 4 doses.) the order was then
rewritten correctly
MS 1/4 gr. IV q3h prn pain. This order for morphine was mistakenly transcribed as
morphine 15 mg IV q3h pr The 75 y.o pt recieved one dose resulting in profound
lethargy and resp arrest requiring naloxone to revive the pt. The result of this
uncommon abbreviation was catastrophic.
SOLUTIONS | 100% VERIFIED
Medical Errors Statistics/Prevalence - Third leading cause of death in the U.S.
More than 250,000 people die each year from medical mistakes
400,000 drug-related injuries occur in hospitals and 800,000 in long-term care settings
each year
Medication errors injury approximately 1.3 billion people annually
Medical errors cost the nation 1 trillion each year
Not all errors are reported
Medical Errors Consequences - Medical penalizes hospitals for safety incidents
Medicaid to cease reimbursement to hospitals for "never events" and avoidable errors
Computerized systems still miss major drug errors
Wrong dose, wrong drug, bad combinations, bad reactions
medication error long definition - any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control of the
health care professional, patient or consumer. Such events may be related to
professional practice, health care products, procedures and systems, including
prescribing, order communications, product labeling, packaging and nomenclature,
compounding, dispensing, distribution, administration, education, monitoring, and use
medication errors by stage of the medication process - Administration of improper dose
of medicine accounts for 41% of fatal medication errors
Administration of the wrong drug accounts for 16% of fatal medication errors
using the wrong route of administration accounts for 16% of fatal medication errors
Medication Errors causes - poor communication
poor handwriting
ambiguous directions
medical abbreviations
poor procedures : trailing zeroes
lack of knowledge
similar labeling/packaging : external warning labels
name confusion (lamisal vs lamictal; oxycodone vs oxycontin)
Pt misunderstanding
Pt misunderstanding medication error - a 19 year old female was prescribed
spermicidal jelly... four days after using the medication, the patient called her physician
complaining of severe stomach cramps and nausea. It was found that the patient was
spreading the jelly on her toast every morning.
, Name confusion - A verbal order from a physician for Lamictal was mistaken as
Lamisal (anti-fungal) for a patient with epilepsy .Fortunately, there was no adverse
event as the error was caught when the pharmacist was counseling the patient
regarding the drug's indication.
A physician wrote for Oxycodone (immediate release) 10 mg q4h prn pain but the nurse
pulled Oxycontin (sustained release) 10 mg tablets and administered this to the patient.
When attempting to reorder more, it was revealed that the patient had been given the
wrong medication
Similar labeling/Packaging - A patient was ordered esmolol for supra-ventricular
tachycardia and was ordered a bolus followed by a continuous infusion. The nurse
inadvertently used the concentrate (which requires dilution prior to use) rather than the
single-dose vial to administer the loading dose. The patient went into complete heart
block and died. The use of external warning label may have prevented this error.
A patient was ordered hydralazine 10 mg IV q6h (patient with a h/o advanced heart
failure).. the pharmacist inadvertently dispensed verapamil 5 mg/2ml vials because the
manufacturers vials are identical in color, size, and labeling.. the nurse administered
verapamil 5mg q6h x 3 doses before this errors was realized. pt's bp dropped to 80/60,
HR dropped to 42 and tele: heart block
lack of knowledge - a 26 y.o f pt, s/p delivery of her first chld was ordered an epidural of
fentanyl plus bupivacaine for pain. The pharmacist, recently licensed, prepared this
order with NS solution containing a preservative. As a result of her lack of experience,
the pt seized. this error lengthened her stay 3 days and resulted in a lawsuit
An orthopedic surgeon wrote for Demerol 75 mg IV q3h postoperatively for a 88 year
old male w/ a hx of renal impairment. 2 days after surgery this patient experienced a
grand-mal seizure and suffered stroke. This lack of knowledge caused an extended
hospital stay as well as a lawsuit
Poor procedures - A physician wrote an order for warfarin 1.0 mg qd for an 82 y.o
male... the dose was transcribed to the MAR as 10 mg daily and the dose was
administered to the patient... 3 days late the INR was >5, H/H dropped to 7.6/30 and the
patient had blood in his urine. The practice of having the charge RN double check the
transcription process would have avoided this error
Medical Abbreviations - 5 ASA tid. This order for mesalamine (5 aminiosalicylic acid)
was mistakenly read as 5 aspirin tablets 3 times a day. luckily the pt asked the
physician why she was taking that much aspirin (after 4 doses.) the order was then
rewritten correctly
MS 1/4 gr. IV q3h prn pain. This order for morphine was mistakenly transcribed as
morphine 15 mg IV q3h pr The 75 y.o pt recieved one dose resulting in profound
lethargy and resp arrest requiring naloxone to revive the pt. The result of this
uncommon abbreviation was catastrophic.
