'Medication errors,' edited by Michael R. Cohen. Pp xx + 336. Price $70. Washington: American Pharmaceutical Association, 1999. ISBN 0 917330 89 7
This book is published at a time of growing concern about medication errors and measures to improve patient safety. It clearly illustrates the extent of the problem relating to medication errors and describes the challenges facing health care providers and the pharmaceutical industry in reducing these preventable mistakes.
The opening chapter looks at the common causes of medication errors. These include failed communications, poor drug distribution practices, dose miscalculations, drug and drug-device related problems, incorrect drug administration and lack of patient education. Familiar errors, such as 10-fold overdoses resulting from the omission of a zero before a decimal point, are highlighted.
Computer generated labels are also shown to be a source of error, particularly if a pharmacist dispenses a medicine from the computer generated label and not from the original prescription.
"Failure mode and effects analysis" is introduced as a tool for error prevention. For each medicine, the analysis seeks to determine what will happen if a health provider mistakes the medicine for another because of packaging, administers the wrong dose, administers the medicine to the wrong patient, or by the wrong route or at the wrong rate, omits a dose or administers a dose at the wrong time.
One chapter is devoted to a small number of high-risk medicines, such as intravenous potassium chloride, magnesium sulphate and digoxin. Much advice is given on the safe use of these dangerous products, but restricting their availability by storing them in a Controlled Drugs cupboard along with the narcotics would cause some eyebrows to be raised in Britain.
Other chapters deal with preventing errors in prescribing, dispensing and administration.
Many errors appear to relate to telephone prescribing and the transcribing of prescription details, practices which are not common in Britain. Automation is widely used in the drug distribution and dispensing processes in the United States. This technology can either limit or increase opportunities for error and while automation is in its infancy in Britain, it is an area of potential growth and much can be learned from the mistakes of the early pioneers.
The pharmaceutical industry should take note of the chapters on errors caused by poor packaging and labelling and confusing pharmaceutical trademarks. Some of the errors described in this book result from practices that occur mainly in the US but the messages are still loud and clear. Medication errors can be reduced through a review process that has wide multidisciplinary participation and a no-blame culture.
Reviewer - Laurence A. Goldberg Laurence Goldberg is a consultant pharmacist from Bury, Lancashire