Case Study Medical Error

Case Study Medical Error-19
A medication (a medicinal product) is ‘a product that contains a compound with proven biological effects, plus excipients or excipients only; it may also contain contaminants; the active compound is usually a drug or prodrug, but may be a cellular element’.

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Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility).

Avoiding medication errors is important in balanced prescribing, which is the use of a medicine that is appropriate to the patient's condition and, within the limits created by the uncertainty that attends therapeutic decisions, in a dosage regimen that optimizes the balance of benefit to harm.

An ADR is ‘an appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product’.

Some medication errors result in ADRs but many do not; occasionally a medication error can result in an adverse event that is not an ADR (for example, when a cannula penetrates a blood vessel and a haematoma results).

From 1983 to 1993 the numbers of deaths from medication errors and adverse reactions to medicines used in US hospitals increased from 2876 to 7391 These increases are not surprising—in recent years hospitals have seen increased throughput of patients, new drugs have emerged that are increasingly difficult to use safely and effectively, medical care has become more complex and specialized, and the population has aged, factors that tend to increase the risk of medication errors.

The best way to understand how medication errors happen and how to avoid them is to consider their classification, which can be contextual, modal, or psychological.

A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient.

Medication errors can occur in deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors); manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging); dispensing the formulation (wrong drug, wrong formulation, wrong label); administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration); monitoring therapy (failing to alter therapy when required, erroneous alteration).

an accident or unplanned pregnancy), or any unexpected deterioration in a concurrent illness’.

If an adverse event occurs while an individual is taking a drug it could be an adverse drug reaction (ADR).


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