The drama of patients dying from overdoses of drugs because of a misplaced decimal point, or because the names of two drugs were confused, only emphasises the difficulties.
THE LESSONS FROM DEATHS RELATED
TO MEDICATION
Previous
studies have highlighted slips as a major cause of medication errors (Koren,
Barzilay and Greenwald, 1986). The drama of patients dying from overdoses of
drugs because of a misplaced deci-mal point, or because the names of two drugs
were confused, only emphasises the difficulties. However, in this data set, we
found that slips were much rarer than mistakes and that medication errors were
themselves a rare cause of death as determined at Coroner’s inquest. The
‘system’ in which drugs are used needs to be improved, and that system includes
both prescribers and patients. Better education, and more relevant information
at the point when doctors prescribe, will help.
Some
drugs, notably warfarin, lithium, opioids and potassium chloride, are difficult
to use safely and require especially careful prescribing and monitoring. This
reality is underlined by the increased number of deaths due to warfarin
demonstrated in the third series. The number of deaths due to warfarin
treatment will only fall through improved education and empha-sis on the need
for vigilant monitoring of patients being treated with this drug. Nonetheless,
however safe systems for prescribing, dispensing and admin-istering drugs
become, patients will continue to die from ADRs. That problem can only be
mitigated by a more careful assessment of risks and benefits in prescribing for
each patient and every drug and by the development of safer drugs.
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