Medication errors- the elephant in the room

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2024-06-10T10:19:19+05:00 Shumaila Kauser

Experts say that at least half a million people in Pakistan die annually due to medication errors as compared to road accidents. Discussions in the healthcare industry frequently center on cutting-edge medical innovations, creative therapies, and ground-breaking research. However, despite the bright spotlight shining on these issues, a crucial issue—medication errors—remains hidden from view. These unintentional errors in patient care have become a quiet elephant in academic literature and debate. Although the academic community in the field of healthcare takes pride in its pursuit of excellence, it is crucial to address this serious issue with better terminology and increased awareness. A medication error is any mistake that can occur at any step of the medicine process starting from physician prescription tillit goes into the hands of the patient for use or a nurse for administration in a hospital setting and the steps include prescribing, transcribing, dispensing, filling, administration, and counseling the patient and because of this mistake patient get losses which could be reversible or vice versa. For example, temporary kidney damage due to the wrong dose of a drug comes under irreversible loss however cardiotoxicity with a higher dose of a drug has a tendency to harm cardiac functions.

If we look into the causes of such mistakes, are frequently the result of ignorance, misunderstanding, or insufficient training of healthcare professionals. Physicians, in order to maintain their reputation and patients for their personal satisfaction and hence validate the physician competencies in order to be in the vicious thought process of compulsive prescribing and want a handful of amazing colored tablets and capsule dosage forms and an indifferent concept of “ garamdawai” which is self-considered to be taken with milk in any case however there is a certain class of medicines which is absolutely contraindicated with dairy products and hence no desirable results are being achieved,. So here comes the concept of poly pharmacy. According to the World Health Organization (WHO), poly pharmacy has overtaken even traffic accidents as the third-leading cause of death, worrying claiming that it is a subtle but important factor in medical errors. The term “poly pharmacy” dominates the complex world of contemporary medicine, describing a situation in which five or more different prescribed medications are taken at the same time. The troubling reality behind this seemingly innocent practice, however, has started to throw a lengthy shadow over patient safety and healthcare effectiveness. I still remember that fake medicine event at the Punjab Institute of Cardiology (PIC) Lahore, which took the lives of above 100 patients who took a counterfeit antihypertensive medicine the crisis taken into consideration when different patients of PIC started appearing in different hospitals with a significant drop in platelets and white blood cells and bleeding from different parts of the body which were identified very late that these were the adverse drug reaction of the counterfeit drug, the manufacturing unit of that pharmaceutical was sealed by FIA later. But to my surprise, there was no pathway or process for medicine recall in the organization which could timely inform the patients they get that medicine and experienced unwanted effects and putting their lives at risk. The demand for collaboration among healthcare professionals reverberates through the hallways of hospitals and clinics. The skills of doctors, nurses, and pharmacists must come together to build a cohesive partnership. When they work together harmoniously, each note is tuned to achieve the crescendo of the best patient outcomes. However, this harmony is still elusive, with communication and comprehension gaps frequently obstructing the bridge between different fields. To ensure that these medication errors are treated seriously, a multifaceted approach to solving the problem is essential. We should also consider patient-centered care, reconcile medication orders made by doctors and chemists at various levels, and declare that medications with a higher risk of error should be treated strategically. adding encouraging cues, such as labeling them as High alert medications (HAMs), and adding colors that imply damage and error, such as applying red stickers to them to emphasize the need for extreme caution when handling. To improve their skill sets and create professional development plans at organizational levels, training and development plans for healthcare professionals are crucial. Pharma covigilance facilities essentially act as sentinels on the front lines of patient safety. Their commitment to uncovering potential hazards and promoting openness significantly improve the well-being of people, families, and communities. As healthcare continues to be complex, these facilities adapt by embracing technological improvements and broadening their focus to make sure that patient health remains the core value of our medical endeavor and we need to strengthen these centers for better reporting of medication errors and adverse reaction events (ADEs) for better highlighting this challenge.

Shumaila Kauser

The author is an MS student of LUMS and a Pharmacist by profession.

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