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Medmarx! 2001 Data Report Details: Top Drug Errors
Snapshot
Of all the medication errors reported to Medmarx in 2001 involving specific products, four out
of five products reported were high-alert medications. High-alert medications, which are
widely used in the health care setting, have a high risk of patient injury when administered
incorrectly. These products represented 11 percent of all product selections in 2001. High-alert
medications should be packaged, stored, distributed, prescribed, dispensed, and administered
safely to minimize injury risk to patients.
Report Findings
! Of the product reported errors, 91 percent identified a single product.
! Twelve products were involved in 14 patient fatalities: meperidine, iohexol, potassium phosphates, doxorubicin, cocaine, epinephrine, ampicillin, esmolol, morphine, digoxin,heparin, and polyethylene glycol 3350 with electrolytes.
12 Products Involved in Patient Fatalities
Indication
Narcotic used to treat moderate to severe pain Used in diagnosing certain medical problems A group of medicines known as antineoplastics. It is used to treatcertain types of cancers.
Narcotic used as a local anesthetic to numb an area beforesurgery; primarily used before ear, nose, and throat surgeries Stimulant that narrows blood vessels for control of bleeding,increases heart rate, and improves breathing in patients withasthma; also used to treat various allergic reactions and heartconditions Antibiotic used to treat bacterial infections A type of beta-blocker used to slow the heart rate Narcotic used to treat moderate to severe pain Used to improve the strength and efficiency of the heart, tocontrol the rate and rhythm of the heartbeat Anticoagulant or blood thinner that treats or prevents theformation of blood clots Used to clean the bowel before certain tests and surgery A Look at Insulin
Harmful errors involving insulin have been frequently reported since the 1999 data report. For
2001, insulin remains the leading product involved in harmful medication errors. It was
associated most often with improper dose/quantity errors, omission errors, and unauthorized
drug errors.
Health care practitioners prescribe and administer insulin for patients with Type 1 and Type 2 diabetes.
Insulin is available in a variety of formulations and requires individualized treatment protocols that mustbe carefully adjusted based on multiple medical conditions such as heart disease and high blood pressure.
The complexity of the disease and treatment protocols could explain why it is frequently associated withmedication errors.
A Look at Albuterol
Albuterol was the second most frequently reported product associated with medication errors in the 2001
Medmarx database. This data report marks the first time that albuterol was identified among the top five
products involved in medication errors.
Health care practitioners prescribe and administer albuterol to improve breathing in patients with asthma,bronchitis, emphysema and other conditions. Albuterol omissions increased in late spring (May) and latefall (October–December)—a time of year that correlates with the onset of respiratory ailment season.
Top Products by Error Type
Type of Error
Indication
Typically used to treat wheezing and shortness of breath associatedwith asthma and other respiratory ailments Used to treat patients with Type 1 or Type 2 diabetes Antibiotic used to treat various bacterial infections Anti-coagulant or blood thinner that treats or prevents the formation Used to treat patients with Type 1 or Type 2 diabetes Narcotic used to treat moderate to severe pain Used to treat patients with Type 1 or Type 2 diabetes Narcotic used to treat moderate to severe pain Combination narcotic used to treat moderate to severe pain Top 10 Products Involved in Patient Harm
Indication
Used to treat patients with Type 1 or Type 2 diabetes Narcotic used to treat moderate to severe pain Anticoagulant or blood thinner that treats or prevents the formation of blood clots Anticoagulant or blood thinner that treats or prevents the formation of blood clots Used to prevent or treat potassium deficiency Diuretic that reduces circulating blood volume to eliminate excess fluid from the body Antibiotic used to treat various bacterial infections Narcotic used to treat moderate to severe pain Narcotic used to treat moderate to severe pain A calcium channel blocker that facilitates the pumping of the heart in patients withhypertension or angina; it also slows a rapid heartbeat For a copy of the Medmarx 2001 data report, send an e-mail to mediarelations@usp.org. For moreinformation about Medmarx, visit www.medmarx.com.
November 2002

Source: https://www.premierinc.com/safety/safety-share/02-03_downloads/03_top_drug_errors.pdf