The Hidden Dangers of Prescription Medication Errors
By: Stella Wang and Jaylin Hsu
Picture yourself holding a transparent orange bottle, enclosed by a thick, white, child-resistant cap. Most of us associate this image with a prescription pill bottle. While we may dread taking these medications, we assure ourselves that each pill represents a step closer to restoring or maintaining good health. However, this assumption could not be further from the truth. Research has shown that prescription medication errors, a commonly overlooked problem in the healthcare industry, are responsible for thousands of deaths annually in the United States. That is to say, the orange pill bottle that we commonly associate with health betterment may be the last thing we touch before taking our last breath.
Prescription medication errors are defined as providing patients with incorrect medication or dosage due to a plethora of avoidable mistakes. These include misclicks or misselections on computer screens, blunders in assigning the correct dosage of a drug, or confusion between drugs with similar names by medical professionals, who may also fail to consider adverse medication interactions. Of course, the pharmaceutical industry also possesses liability in this problem due to possible packaging and labeling errors that go unchecked. Out of all these problems, research has shown that ordering errors, which include prescribing the wrong medication, dosage, or frequency, comprise half of prescription medication errors. Unfortunately and unsurprisingly, these errors can be attributed to poor or illegible handwriting by the provider. All in all, prescription medication errors result in an accrued financial burden of over 42 billion dollars for just the United States alone.
So what are the root causes of these errors that are so costly in terms of finances, injuries, and mortality rates? One central cause may be a shortage of healthcare providers. A doctor who is trying to get through hundreds of patients a day will likely experience high levels of fatigue, which may result in a myriad of negative consequences, including not being able to give adequate thought to a patient’s medication treatment plan. Overlooking specific details may increase the likelihood of a prescription error. Specifically, the healthcare provider may fail to ask the patient if they are on any other medications. Without this knowledge, they may prescribe a medication that causes a negative interaction with the patient’s existing medications. Furthermore, an interesting statistic has demonstrated that certain types of medication are more prone to being prescribed with error, including antibiotics and analgesics, which have a high prescription rate. The prevalent use of these medications may cause familiarity bias on the part of the healthcare provider, as they may fail to account for potential drug interactions when they write prescriptions. Certain antibiotics may also require specific dosing. A study conducted in 2019 by Hasan et al. found that dosage errors for antibiotics were common in patients with severe sepsis or septic shock. In the ICU in particular, appropriate antibiotic dosing continues to remain a controversial issue as providers try to determine the best method of care for their patients.
Although there exists numerous root causes of prescription medication errors, there are several interventions that can be taken. For one, the advancement of technology poses a significant advantage as automation can be used to reduce prescription errors. Using electronic prescription systems would help mitigate errors in failing to account for drug interactions, as the system would be able to check for those. Additionally, this would reduce physician errors due to fatigue, and overall serve as a cheaper and safer option to prescribing medications. However, one challenge associated with the mass implementation of this technology is the need for comprehensive and accurate patient information data entry. Without adequate information about the patient’s health, the automated system could also produce an error in prescription that could do more harm than good. However, these issues can be identified and fixed over time as the program becomes more widely used. Another potential point of intervention to minimize prescription errors is increased collaboration of different healthcare providers on multiple levels. More emphasis should be placed on the role of the pharmacist in proofreading physician prescriptions and ensuring that the medication is appropriately dispensed to the patient. As they often serve as the point of contact between the patient and their medication, they can also be better trained to perform comprehensive consultations for the patient to ensure that no medical history is overlooked.
Prescription errors are more prevalent than we may be aware and pose a significant threat to patient safety. Addressing this issue requires a multifaceted approach, including the usage of technology and improvement of communication across levels of healthcare. Raising awareness about the root causes of these errors and performing appropriate interventions is the first step towards minimizing risks and improving patient outcomes.
Stella and Jaylin are both incoming third years, Molecular Cell and Developmental Biology majors, and THINQ Interns.
Works Cited
Dosing errors of empirical antibiotics in critically ill patients with severe sepsis or septic shock: A prospective observational study. (2019). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6619455/
E-prescribing. (2022, July 28). Centers for Medicare & Medicaid Services | CMS. https://www.cms.gov/medicare/e-health/eprescribing
Medication dispensing errors and prevention. (2022, July 3). National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK519065/
WHO launches global effort to halve medication-related errors in 5 years. (2017, March 29). WHO | World Health Organization. https://www.who.int/news/item/29-03-2017-who-launches-global-effort-to-halve-medication-related-errors-in-5-years
