Position Statement: Medication Errors and Adverse Drug Reactions or Events
American College of Medical Toxicology
Kenneth Kulig, MD
Int J Med Toxicol 2001; 4(1): 13
Medication errors are mistakes involving pharmaceuticals, usually due to human error,
whether or not patient harm results. Common causes of these mistakes include look-alike or
sound-alike medications, illegible handwriting, misplaced or misinterpreted decimal
points, wrong drug, wrong patient, wrong time, or wrong dose. Data are usually collected
by hospital pharmacies, quality improvement departments, and physician peer review
Adverse Drug Reactions (ADRís) are any undesirable effects of a drug. Adverse Drug
Events (ADEís) include the omission of the properly prescribed medication due to
noncompliance or medication error. Common causes of ADRís include known side effects,
drug-drug interactions, drug-alternative medicine interactions, true drug allergies, and
medication errors. Data are collected by the Medwatch program at the FDA, and by drug
manufacturers who then also report them to the FDA. Underreporting is common, even among
toxicologists. Preventable Adverse Drug Events are those caused by medication errors.
Medication errors and adverse drug reactions are common and costly. Estimates of
hospitalized patients experiencing them has ranged from 1.5% to 35%, depending on the
population studied, the adequacy of reporting, and the case definitions used. Fatal drug
reactions are estimated to occur in 0.32% of hospitalized patients. Between 1.1 % and 8.5
% of all hospital admissions are reportedly caused by adverse drug reactions. Many of
these cases are preventable, but this requires sufficient reporting, investigation,
identification and elimination of systems errors, and aggressive education of health care
Medical toxicologists, particularly those that are hospital based, are in a unique
position to investigate the causes of, and help decrease the incidence of, both medication
errors and adverse drug reactions in their institutions. By using their special skills and
training, and becoming involved in groups such as the Pharmacy and Therapeutics Committee,
medical toxicologists can directly improve patient care by helping to reduce the incidence
of preventable adverse drug events. Educational presentations on these issues by
toxicologists to their hospital staffs should be beneficial as well. They should encourage
patients to be proactive in their care and to ask questions about their medications.
Toxicologists should help develop and encourage computerized order entry and other
preventative measures (i.e. bar coding of medications) in their institutions whenever
possible. ACMT encourages these practices among its members.
ACMT also encourages all of its members to be diligent in reporting medication errors
to the hospital in which they occur, and ADRís to Medwatch at the FDA. This can be
easily done via Internet: www.fda.gov/medwatch
Finally, ACMT encourages drug manufacturers to be very diligent at alerting physicians
about potential problems they have identified such as in studies identifying potential
adverse effects and mechanisms (whether to be published or remain unpublished), newly
identified drug-drug interactions, patterns of serious ADRís , and sound-alike or
look-alike medication errors. Toxicologist, like other physicians, need this information
to properly care for their patients.
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Copyright 1999-2003, American College of Medical Toxicology.