It is terrifying to know the truth -- doctors are injuring and killing patients every day because they just aren't careful enough. The medications they prescribe grow ever more powerful -- and more powerful medications, like more powerful firearms, means more likely to cause harm if doctors are too quick to pull the trigger, or grow careless about their aim. Good doctors don't take needless risks with their patients' safety -- but there are a lot of doctors out there, and too many are willing to roll the dice too quickly and too often. Those doctors are gambling with their patients lives -- and when the doctor guesses wrong, it is the patient who pays the debt, not only with money, but with pain and injury -- and sometimes with their lives.

1) 1 in 7 Medicare patients harmed during hospital stay

2) Thirty percent of surgical patient charts were not documented for drug allergy

3) Adverse Drug Events, Adverse Drug Reactions and Medication Errors

Frequently Asked Questions. VA Center for Medication Safety

2. What is an adverse drug reaction (ADR)?

An adverse drug reaction is a "response to a drug which is noxious and unintended and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for the modification of physiologic function." Note that there is a causal link between a drug and an adverse drug reaction. In sum, an adverse drug reaction is harm directly caused by the drug at normal doses, during normal use.

3. How does an ADR differ from a side effect or allergy?

An allergy is an adverse drug reaction mediated by an immune response (e.g., rash, hives). A side effect is an expected and known effect of a drug that is not the intended therapeutic outcome. The term "side effect" tends to norminalize the concept of injury from drugs. It has been recommended that this term should generally be avoided in favor of adverse drug reaction.

4. What is a medication error?

Medication errors are mishaps that occur during prescribing, transcribing, dispensing, administering, adherence, or monitoring a drug. Examples of medication errors include misreading or miswriting a prescription. Medication errors that are stopped before harm can occur are sometimes called "near misses" or "close calls" or more formally, a potential adverse drug event. Not all prescribing errors lead to adverse outcomes. Some do not cause harm, while others are caught before harm can occur ("near-misses"). Medication errors are more common than adverse drug events, but result in harm less than 1% of the time. About 25% of adverse drug events are due to medication errors. Nebecker et al. Ann Intern Med 2004; 140: 795-801.

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4) Abstract

Adverse drug events cause a large number of injuries, and adverse events caused by medications administered in the face of known allergies represent an important preventable cause of patient harm. Computerized systems can effectively prevent reactions due to known allergies, but building an effective allergy prevention feature is challenging and presents many interesting informatics issues that have both methodological and operational implications. In this paper, we present the experiences from one large delivery system in delivering allergy-related decision support, discuss some of the different approaches that we have used, and then propose a future approach. We also discuss the methodological, behavioral, and operational issues that have arisen which have a major impact on success. Key factors in drug-allergy checking include storing patient allergy data in a single common repository, representing allergy data using suitable terminologies and creating groups of allergies for inferencing purposes, being judicious about which allergy warnings to display, conveying the reaction that the patient has experienced when exposed to the drug to inform the provider of the importance of the warning, and perhaps most important, implementing strategies to optimize the likelihood that allergy information will be entered.  (http://www.ncbi.nlm.nih.gov/pubmed/14552848)

5) Allergy Status Poster from Patient Safety Federation IUK)

6) "Unfortunately, the frequency with which something goes wrong is significantly worrisome. In fact, 61 percent of hospital patients in America are worried about getting the wrong medication. Annually in the United States, up to 7,000 deaths-many of them preventable-are associated with medication-related errors. Within the CRICO-insured institutions, malpractice claims involving med-errors cost about $5 million per year. That is only a fraction of the cost associated with the vast majority of medication errors that-although they don't lead to lawsuits-incur millions of dollars in prolonged hospital stays, delayed surgery, wasted supplies, and other preventable inefficiencies." (http://www.rmf.harvard.edu/education-interventions/materials-for-instructors/medication-management/index.aspx)

7) Medical Mistakes: 28 errors that should never happen

"The National Quality Forum, a nonprofit health care safety agency, has created a list of 28 so-called "never events" that detail avoidable errors. The list includes the following injuries, infections or conditions: . . . 12. Patient death or serious disability associated with a medication error.(http://www.msnbc.msn.com/id/26081421)