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Did You Know? > Medication Omission or Errors |
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Medication Omission or Errors |
FACT |
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More than half of respondents in the Health and Safety Survey to Improve Patient Safety in End Stage Renal Disease conducted by the RPA indicated that a patient was never given the wrong medication (57%) or given medication at the wrong time (54%). |
Health and Safety Survey to Improve Patient Safety in End Stage Renal Disease, page 8 |
The most likely medication error appears to be a patient failing to receive one of their medications (63% sometimes or rarely) or being given the wrong dose of a medication (37% sometimes or rarely). |
Health and Safety Survey to Improve Patient Safety in End Stage Renal Disease, page 8 |
Most ESRD patients take between six and 10 medications per day. While mediation errors occur infrequently, considering the number and occurrences of medications taken, the effect of medication omissions may be quite large, particularly when assessed over longer time frames. |
Health and Safety Survey to Improve Patient Safety in End Stage Renal Disease, page 18 |
A study of medication-related problems in hemodialysis patients found a positive correlation between problems and number of co-morbidities. The results showed one medication-related problem for every 3.1 medication exposures. Most common problems were:
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H. J. Manley et al., "Factors Associated With Medication-Related Problems in Ambulatory Hemodialysis Patients," American Journal of Kidney Disease 41, no. 2. (February 2003): 386-393. |
The prevalence of medication errors within dialysis facilities is unknown. Facilities may underestimate the number of medication errors that occur. One small chain of dialysis facilities reported after institution of a fully integrated electronic medical record, medication errors, predicted at <1%/month were found to be 12.5%. Following trend identification and staff re-education, errors dropped to an average of 2%/month. |
J. P. Capelli, M. Jacoby, K. Taraschi, "Enhancing Dialysis Services, Revenue, Quality, and Efficiency Through Computerization. The Impact of Medication Error Reduction," Nephrology News & Issues 16, no. 13 (December 2002): 34-36, 38-41. |
| Health professionals who continually update their knowledge of drugs make fewer medication errors than those who do not. | A. Pié and T.L. Warholak, "Medication Safety: What You Can Do to Prevent Errors" Renal Business Today. 3(12) (December 2008): 28-31. |
| Anticoagulants (inadequate therapeutic dosing, no laboratory follow-up); cardiovascular agents (overdose); chemotherapeutic agents (overdose); diuretics (overdose, no laboratory follow-up); diabetic medications (overdose, wrong type of insulin); nonsteroidal anti-inflammatory drugs (extended use, overdose); and total parenteral nutrition solutions (given peripherally, inaccurate component amount) are among the ten drug types that are identified as being associated with common errors. | R.G. Hughes and E. Ortiz, "Medication Errors: Why They Happen, and How They Can be Prevented" American Journal of Nursing. 2005;105(3):14-24. |
| Using "quick check" charts for common medication interactions can help reduce math and drug knowledge errors. | A. Pié and T.L. Warholak, "Medication Safety: What You Can Do to Prevent Errors" Renal Business Today. 3(12) (December 2008): 28-31. |
| Warfarin is frequently cites as a leading drug involved in adverse drug events. Patients who reported receiving medication instructions from a physician or nurse as well as a pharmacist, had a 60% reduced rate of a wayfarin-related hospitalization in the subsequent two years. | J.P. Metlay, S. Hennessy, A.R. Localio, X. Han, W. Yang, A. Cohen, et al. "Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events." Journal of General Internal Medicine (October 2008) 23: 1589-94. |
| According to the Institute for Healthcare Improvement, up to 46 percent of medication errors occur when new orders are written at patient admission or discharge. | J. Mansur. Enhanced Medication Safety. Joint Commission |
| A 2008 study evaluating the potential impact of medication reconciliation and optimization in the ambulatory care setting at the time of patient transfer from an in-center dialysis unit to a satellite dialysis unit found that 78.8% of patients had at least one unintended medication variance | S. Ledger, G. Choma, "Medication reconciliation in hemodialysis patients." CANNT J. 2008;18(4): 41-3. |
| A 2008 study evaluating the potential impact of medication reconciliation and optimization in the ambulatory care setting at the time of patient transfer from an in-center dialysis unit to a satellite dialysis unit found the majority of unintended variances (56%) were caused by the physician/nurse practitioner omitting an order for medication that the patient was taking. | S. Ledger, G. Choma, "Medication reconciliation in hemodialysis patients." CANNT J. 2008;18(4): 41-3. |
