Zero Tolerance: Why Even Minuscule Risks in Medication Safety Cannot Be Ignored

9th August, 2024 - 7:20 am Categories: Mediation Act News & Updates 0 Comments

When it comes to healthcare, probably the most sensitive topic that requires rigorous strictness and carefulness is the application of medicinal products. It is to emphasize the fact that the concept of ‘do no harm’ is more than just an adage, it is the primary concept that is epitomizing the significance of medication security. In this blog post let the reader understand why even the remotest risk of confusion in medicinal products is not permissible and, further, how this position can affect healthcare professionals, drug manufacturers, and consumers.

To elaborate further about medication errors, we have to know about their possible implications. Dieckmann, et al., in their study conducted in Journal of Patient Safety pointed out that the U. S hospital deaths exceeded 400,000 due to preventable harm of which medication errors formed part of. Although the errors are not always lethal, they develop severe consequences that include increased length of hospital stay and health problems.

An example could be a patient who is given a smaller dose of a blood thinner because the initial dose administered was from a similar appearing vial. The repercussions could vary from simple cases of bleeding to provisions of fatal blood clots. In such situations, a slight change of slope of any of the segments can bring about a zero value of the overall slope and rating. probability of error is once in a hundred to 0 if it is one percent chance of error. 1% too much.

The Ripple Effect of Medication Errors

Such mistakes have far-reaching consequences that go beyond patients’ direct physical well-being. There are significant economic, legal, and psychological repercussions to consider: There are significant economic, legal, and psychological repercussions to consider:

1. Economic Burden: A preventable adverse drug event was defined as an ADE that could have been prevented if all of the CPG recommendations were followed A study in Journal of Medical Economics noted that direct medical cost of each of these events amounted to $8,750 . Add this to the thousands of annual mistakes, and the magnitudes of damages resulting from them skyrocket.
2. Legal Ramifications: This means that medication errors cause many malpractice suits, which translates to significant legal expenses and negative impacts on the health care organizations’ image.
3. Psychological Impact: In cases of medication errors, the psychological impact goes far and affects the healthcare professionals, and common symptoms are a reduction in job satisfaction, burnout and occurrence of what is referred to as second victim syndrome .
4. Erosion of Trust: What is more dangerous, medication errors demoralize people’s confidence in the healthcare systems and this can make patients delay necessary treatments or even doubt anything a medical practitioner tells them.

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Complications of Current Day Health Care

There are many actors involved within the health care system, which has also become much more complicated as the years pass; The quest to eliminate medication errors completely becomes even more difficult. Several factors contribute to this complexity:Several factors contribute to this complexity:

1. Polypharmacy: In today’s healthcare scene, population growth trends by sex and age is mean and population is generally aging and chronic illness is common so many patients are on multiple medication hence high likelihood of combination effects and medication errors.
2. Similar Drug Names and Packaging: The availability of the numerous pharmaceutical products has resulted in the common use of the same naming and packaging hence a high possibility of confusion.
3. High-Stress Environments: About working conditions of healthcare professionals, it can be stated that they usually perform at conditions that have high levels of risk and pressure.
4. Technological Integration: Even though EHR and CPOE have decrease some forms of mistakes they have created new potential avenues of error.

Strategies for Achieving Zero Tolerance

Given the unacceptable nature of even minor risks in medication safety, a multifaceted approach is necessary to strive for perfection: Given the unacceptable nature of even minor risks in medication safety, a multifaceted approach is necessary to strive for perfection:

1. The Standardization and Simplification Adopting universal practices in methods of giving out medicine can reduce or even eliminate the errors that are likely to occur. This encompasses the labelling of objects, compliance to units of measurement and relating to protocols and signals.
2. Technology as a Safeguard While technology brings new hazard into lives, it can become a means of avoiding mistakes. Such systems as the barcode medication administration systems have been clearly proved to decrease the instances of medication errors by about 41%.
3. Human Factors Engineering Enveloping the designing of the healthcare environment and the creation of its processes with the understanding of human psychology enables the reduction of errors. This might encompass changes into the layout of packaging of medicines to be different or the use of “tall man” letters to differentiate related names for medicines.
4. Education and Training Ongoing education and training of the healthcare professionals on medication safety, role plays depicting real life risk associated events help in continuous identification of the errors and earlier rectification of them.
5. Safety Culture for the organization means that there has to be a culture change to encourage people to look for errors and report them without fear of being penalized. This makes it possible to learn and therefore, improve the practice regularly.
6. Teaching Page Sharing information with the patient about their drugs and encouraging the patient to engage in a question-and-answer session with the doctor adds another safety measure. Patients can be helpful in preventing medication errors and are the last resort in such incidences.
7. Minimizing the Source of Confusion Stringent regulations governing the drug naming, labeling as well as packaging imposed on the pharmaceutical companies can assist in minimizing the problem.

Case Studies: This kind of knowledge management is by learning from the near misses.

Issues close calls—situations that did not harm the patient but involved error-producing factors in medication use—can yield useful information about the method’s weak links.

Case 1: Look-Alike Packaging After careful observation and analysis of a patient’s medical record, this paper presents the first case with look-alike packaging in an ED; a nurse nearly administered paralytic agent instead of an anti-nausea medication. This incident prompted a systems-wide effort to relocate high-alert medications and require the double-checking of specific drug types by two different people.

Case Study 2: Sound-Alike Drug Names In one particular case a pharmacist was able to stall a prescription error where a patient was prescribed “Celebrex” for pain while they meant “Celexa” for anti depression. This event led to the advocacy for the prescription of both the generic and brand name of the medicine and putting up of computerized sound-alike drug pairs alerts.

To recap, this paper examined the responsibilities of the players involved with pharmaceuticals with particular focus on the pharmaceutical companies.

Industry participants involved with medication safety include pharmaceutical firms which are involved right from the new drug development, new drug application and marketing and monitoring the post-marketing performance of a product.

1. Thoughtful Naming and Packaging: Market research has it that new products’ names and the packaging design must not be similar to existing products.
2. Clear Labeling and Instructions: Most of the patients had difficulties in understanding labeling and its instructions thus proper labeling and patient information should be clear and devoid of any ambiguity.
3. Post-Market Surveillance: Performing constant surveillance over their products as used in the market can assist them in effectively solving any possible problems with the safety of the products.
4. Collaboration with Healthcare Providers: The candor of the communication between the pharmaceutical companies and the healthcare providers can help to respond to new safety issues quickly.

The Future of Medication Safety

As we look to the future, several emerging technologies and approaches hold promise for further reducing medication errors:

1. Artificial Intelligence: Machine learning algorithms could potentially identify patterns and predict potential medication errors before they occur.
2. Personalized Medicine: As treatment becomes more tailored to individual genetic profiles, the risk of adverse drug reactions may decrease.
3. Automated Dispensing Systems: Robotic systems for medication dispensing could reduce human error in pharmacy settings.
4. Blockchain Technology: This could provide a secure, transparent system for tracking medications from manufacturer to patient, reducing the risk of counterfeit drugs.

Conclusion

In the high-stakes world of healthcare, there is no room for complacency when it comes to medication safety. Even the slightest probability of confusion in medicinal products is unacceptable because the consequences can be dire and far-reaching. Achieving zero tolerance for medication errors requires a concerted effort from all stakeholders—healthcare providers, pharmaceutical companies, regulators, and patients.

While perfection may seem an impossible goal, it is the relentless pursuit of this ideal that drives continuous improvement in medication safety. By implementing robust systems, leveraging technology, fostering a culture of safety, and remaining vigilant, we can work towards a future where medication errors become truly rare events.

The journey towards zero medication errors is ongoing, but it is a journey we must undertake. After all, when it comes to patient safety, anything less than our absolute best effort is, quite simply, not good enough.

Author: Vanshika, in case of any queries please contact/write back to us via email to chhavi@khuranaandkhurana.com or at  Khurana & Khurana, Advocates and IP Attorney.

REFERENCES

[1] James, J. T. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122-128.

[2] Slight, S. P., et al. (2018). The causes of prescribing errors in English general practices: a qualitative study. British Journal of General Practice, 68(673), e713-e723.

[3] Seys, D., et al. (2013). Health care professionals as second victims after adverse events: a systematic review. Evaluation & the Health Professions, 36(2), 135-162.

[4] Poon, E. G., et al. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707.