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Jan 2024

Medication Errors Persist Despite Provider Efforts

Despite a concerted effort by the healthcare community, preventable medication errors continue to put both patients and providers alike at risk.  These errors are not limited to just prescription medications, but also include OTC medications and supplements.

Exacerbating this potential for medication errors is the sheer quantity of prescription, over-the-counter medications, supplements, herbs, and other health products in the market.  According to the NIH, these errors are not limited to one type of provider or one level of care.  They include prescribing, initial pharmacy dispensation, inpatient and ambulatory care, and SNFs.  

To give an example of how the challenge of further reducing medication errors persists, consider that the U.S. Food and Drug Administration (FDA) receives upward of 100,000 reports every year about medication errors and that more than 40 percent of Americans report having been involved with a medication error either personally or secondhand.  The adverse drug events (ADEs) caused by these errors account for more than 3.5 million physician office visits and 1 million ED visits each year.  These data translate into more than 7 million patients impacted by medication errors and more than $20 billion annually across all provider settings.  

Medication errors greatly impact patient overall health and quality of life.  

These include dangerous side effects, avoidable hospitalizations and even death.  It is estimated that over 7,000 people die each year due to medication errors. Another 1.3 million people are injured every year because of these errors.

And while many people may think that providers and their staff are the cause of these medication errors, it’s important to recognize that patients and caregivers may also be the cause.  In their case, the error may be the result of not taking or giving a medication at the correct dose, at the right time or in the correct manner, and/or medication allergies. They also may not fill or refill the prescriptions as indicated, nor report side effects to their provider, or simply just stop taking the medication for a variety of reasons.  All put their health – and their providers – at risk.

The widespread implementation of electronic health records held – and still holds – the potential to address many preventable medication errors both by increasing accuracy in the provider setting as well as facilitating medication reconciliation.  The latter, of course, is designed to ensure the most complete and accurate possible patient medication information and history as the patient transitions from one type of care to another.

Unfortunately, most patients have multiple electronic records for their visits to different providers and are taking multiple medications.  Instead of making it easier to track patient medications from admission to discharge, having a variety of records (and often in different or incompatible formats) can make medication reconciliation more complicated. This is caused by variations in how providers gather a medication history and the multiple players, including patients themselves, involved in compiling it.  Each introduces its own potential for error.  Without an effective and accurate medication reconciliation, what patients are taking (or not taking) often does not match with a provider may have on their medication list.  This, of course, is a medication error waiting to happen.

As I wrote in this space about medication errors and readmissions, almost half of all patients have a clinically significant medication error within a month after discharge. These types of errors along with general prescription noncompliance and ADEs create a perfect storm for readmission risk to where more than 10 percent of 30-day hospital readmissions can be attributed to adverse drug events (ADEs), the bulk of which are preventable.

Medication errors occur at various stages of the patient journey.  For example, one study found that some half of patients admitted to a general medicine ward had at least one unintended medication discrepancy.  In the ED, more than half of patients had at least one unintended discrepancy between their admission orders and what they were taking at home.  In general, around 40 percent of medication errors are believed to happen because of errors in reconciliation when a patient is handed off from one type of care to another.  And, understandably, older patients run a higher risk of being impacted by a medication error given the number of different medications they take.

Providers are also negatively impacted by medication errors.  Caring for patients who have experienced medication errors costs over $40 billion a year. These types of errors also, understandably, lead to decreased patient satisfaction as well as a general mistrust of healthcare overall.  In extreme cases, these errors can result in malpractice lawsuits, criminal charges, and medical board sanctions.

While it would be impossible to eliminate all medication errors, and great progress has been made to reduce their frequency, there are things that providers can do to help further reduce them.  These include:

  • Taking extra care with ensuring the accuracy of medication reconciliations at every step of the patient journey and especially at intake and discharge
  • Reviewing patient education protocols to ensure the highest possible level of health literacy before discharge to increase the probability of compliance and to reduce boomerang readmissions due to medication errors
  • Consider using an integrated, multipart paper form to be given to patients that includes the initial medication reconciliation of what medications they were taking upon admission, medication changes that occurred during their stay, and what medication instructions they need to follow post discharge
  • Include proactive post-discharge follow-up with patients on their medication regimens to help ensure compliance and reduce the risk of at-home medication errors
  • Create and utilize multi-disciplinary teams to collaborate on medication reconciliations to reduce the risk of omissions, duplications, and input errors
  • Review electronic health record algorithms to ensure they can identify and report on potential medication interactions, prescribing inconsistencies, and recommended dosage/frequency changes

With a continued effort on the part of providers, physicians and the healthcare community, the number of medication errors – and the corresponding risks – can continue to be reduced.  

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