The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error 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.” Oftentimes when we think of medication errors, we think of the acute setting and infamous cases such as the Quaid twins and the heparin error. However, we must remember that medication errors occur in the ambulatory office setting also. Data from Harvard shows that one in nine claims is related to a medication error with half occurring in the office setting. Further, it is estimated that unsafe medication practices are the leading cause of avoidable patient harm, with most errors occurring during medication administration.
Here are some of the most common medication errors that our physician members report to CAP’s Risk Management Hotline.
Scope of Practice Issues
A 2019 review of CAP's closed-claims data revealed that medication errors occurred in nearly half of claims where a medical assistant (MA) was directly responsible for a patient's injury. Errors can occur when staff work outside of their scope, such as when the medical assistant (MA) calls in new prescriptions or refills with changes, which they are not permitted to do. According to the National Institutes of Medicine, prescription errors are among the most expensive claims made. Moreover, when errors are made by staff working outside their scope, the allegation of failure to supervise can also apply, making the claim costlier.
Administration Technique Errors
In the 2019 data review, it was also noted that the majority of medication errors involving MAs were related to injectable medications. An example would be Kenalog. When not administered correctly with the appropriately sized needle and via the Z-track method, it can leak into the fat tissue causing necrosis, pigmentation changes, and dimpling.
Administration of the wrong vaccine can occur because of “look-alike, sound-alike” names, such as mistaking Hep-A for Hep-B or DTaP for Tdap. Additionally, vaccine administration errors have occurred in pediatric practices where staff maintains one “chart” for siblings and a patient has received two doses when the second dose was intended for their sibling.
Prescribing errors can occur when the prescribing provider fails to review patient allergies, current medication lists, and/or contraindications. Pharmacists will sometimes catch these errors, but this cannot be relied on. It’s the prescriber’s responsibility to ensure the appropriateness of the prescription.
Other Common Errors
Unlabeled Syringes: This type of error occurs when syringes prepared for a procedure are placed on the aseptic field without labeling. When this happens, syringes can be easily mixed up, causing the provider to inject the wrong substance or medication.
Name confusion: Some practices use only patient initials when labeling medications; however, this is risky and can lead to a medication being given to the wrong patient. The outcome can range from minor with no injury to severe anaphylaxis.
To reduce the risks of medication errors, we recommend the following:
- Develop policies for staff that includes refill guidelines, scope of practice, medication storage guidelines, and the Six Rights of the Medication Process (right person, dose, medication, route, time, and documentation). Additionally, consider implementing a process requiring all medications be double-checked and verified prior to administration.
- It is important that physicians understand the full scope of practice of an MA as described by the Medical Board of California (MBC). It is best practice to hire MAs that can provide certification of training or can verify training under a licensed physician and can demonstrate competent safe medication practices.
- For MAs giving injections or administering inhalation medications, it is essential that they have the training required and can demonstrate this safely. A physician will be well served to ensure the competency of all staff they supervise.
- Maintain separate medical records for each patient. It is not appropriate to maintain a single chart for siblings or for married couples. It is a recipe for disaster.
- To minimize distractions that can lead to errors, ensure that the area in which medications are stored and prepared is away from busy areas where disruptions can occur. Further, store “look-alike, sound-alike” drugs separately and consider enhanced labeling.
- Provide patients with their medication list and instruct them to carry the list to every appointment to capture changes. Some practices provide patients a list of their medications at time of check-in to allow time to review while waiting to see the provider. It is never a good idea to ask a patient if their medications have changed, without providing a list to review.
Implementation of these risk mitigation strategies and diligence in safe medication practices is essential in all healthcare settings to reduce the risk of errors, patient injury, and potential claims.
Cynthia Mayhan is a CAP Senior Risk Manager and Patient Safety Specialist. Questions or comments related to this article should be directed to cmayhan@CAPphysicians.com.
1. Center for Drug Evaluation and Research. (2019, August 23). Working to reduce medication errors. U.S. Food and Drug Administration. Retrieved December 8, 2021, from https://www.fda.gov/drugs/information-consumers-and-patients-drugs/worki...
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