Medication gone wrong, resulting harm to patient

Hyderabad: Medication errors in terms of prescribing, administering and dispensing drugs to patients are becoming complex and result in preventable harm to the patients. Such mistakes need to be curtailed in the light of adverse drug reaction reports which have been collected from corporate hospitals in the city.

According to the department of pharmaceuticals, adverse drug reaction reports are to be maintained in the hospital and an evaluation of wrongly administered drugs has to be noted and then reviewed by a committee of doctors.

According to estimates collected by the World Health Organisation, out of every 100 hospitalisations, 12 per cent were found to be cases where either a wrong drug is prescribed or a wrong drug administered to the patients.

Dr Shobha Rani, clinical pharmacist said, “Medical errors in terms of prescribing may or may not result in adverse consequences for the patient. However, it is the duty of the pharmacists to check and recheck and work towards preventable measures.”

The departments where these errors are often found to occur are cardiovascular diseases, cancer patients, transplant patients and those suffering from multiple complications.  

Dr Rajesh Balakrishna, clinical pharmacist said, “Medical errors are found to happen when the consultant or his juniors who are writing the drugs do not have adequate knowledge of the drug indications and contraindications. Individual factors like allergies suffered by the patient, co-morbid conditions are some of the factors which have to be taken into account before prescribing medicines. When these are not taken into account adverse drug reactions may occur.”

Also, combination of medicines have to be properly explained to patients because using the drug appropriately is very important. Dr Sharath Reddy, senior interventional cardiologist, said, “Any incidence of wrongly administered drug has to be brought to the notice of the treating physician, nurse and pharmacist. Patients who go through this experience are followed up closely even after counseling as it is clear that they are erring in following the protocol in taking the medicines.”

Dealing with medication errors requires a strong protocol system in hospitals for the problems to be rectified. A senior clinical pharmacist said, “Only a handful of hospitals in the state have proper rectification process.In many cases, these patients are sent to government hospitals which takes away precious time of the patient. But due to lack of knowledge and also proper counseling many patients are found to run from one hospital to another to get a preventable problem treated and precious time is lost. Some of them develop severe complications leading to death.”

Be doubly sure, adopt printing

Confusion due to same sounding names of the medications, hand-written prescriptions and also lack of time are some of the major reasons for medication errors according to various reported case studies in the Indian Journal of Pharmacology.

Dispensing errors have been noted in same sounding drugs like Lasix which contains furoserride which is a direutic and is it mistaken for Losec containing omeprazole for duodenal ulcers. These examples are often seen by pharmacists who have been told to ensure that they prescribe drugs only on written prescriptions.

Even hand-written prescriptions are causing errors and for this reason Computerised Patient Records and Electronic Health Records are being insisted upon to do away with these human errors but the implementation is taking too long.

Dr Sudhir Prasad, senior critical care specialist explained, “The system of capital letter writing has proved to be too time-consuming for doctors. It is very difficult to write in capital letters hence it is not working. Many of them are now switching to computer generated list of medicines to patients.”

Case study
A 60-year-old woman who underwent a by-pass surgery needed a medication to prevent water from entering the lungs. That was not prescribed. The patient came back in 15 days with water in her lungs. The hospital pulled up the consultant and junior doctors for the laxity. The woman took six months to recover and was restricted to consuming just three glasses of water for this period.