CDEX/VALIMED IN THE NEWS
Medication Errors in the U.S.
WHOI-TV Illinois Report
Healthbeat:Valimed
October 20, 2005
Jen Christensen
A medication error is defined as the unintentional administration or use of a drug that could potentially cause harm to the patient. The error may involve providing the wrong drug, giving the wrong dose, administering the wrong form (for example, direct injection of a medication meant to be diluted in an intravenous solution), or not providing medication at the right time.
According to a survey by the Commonwealth Fund, about 16 percent of Americans have experienced a prescription drug error or have a family member who experienced an error. In about 20 percent of cases, the mistake caused a serious problem for the affected patient (like prolonged hospitalization or death).
There are many steps involved from the time a physician orders a prescription until the patient gets the drug. A medication error can be made at any point in the process. Written prescription orders may not be legible, causing a patient to get the wrong drug, wrong dose, or wrong method or timing or administration. Verbal orders may also cause confusion when the pharmacist mistakes sound-alike drugs. Nurses may pull the wrong medication from the shelf or fail to verify the correct medication/dose/route with the patient’s chart. Use of abbreviations can cause further confusion and increase the chance of a drug mix-up.
The ValiMed™ System
All those involved in providing medications to patients are supposed to double-check each prescription order before giving the patient the medication. However, the best-planned systems can still lead to mistakes. Even computerized checks can be imperfect due to human error.
Researchers have developed a new type of drug checking system to verify the correct medication in a prepared drug sample. The technology, called ValiMed™, was first developed to detect explosives. The ValiMed sits on the countertop of the pharmacy. When a medication is mixed, a tiny sample is placed in the machine. ValiMed flashes an ultraviolet light onto the drug. When exposed to the light, the molecules in the sample produce a pattern of fluorescent energy. Every drug has a unique pattern of fluorescence, creating a drug fingerprint. The ValiMed reads the fluorescent fingerprint and compares it against known drug fingerprints in a data library. If the test doesn’t show a match, the sample is retested. If the drug can’t be validated in the second attempt, it’s sent back to the lab.
The University of Michigan Health System is the first hospital in the world to use ValiMed for verifying the identity of prescription drugs. The hospital pharmacy is currently using the system to test 10 commonly used high-risk drugs that are specially prepared for children. Other drugs will be added to the database in the future. For information about the ValiMed system, log on to the website at valimed.com.
AUDIENCE INQUIRY
For information on ValiMed™, valimed.com
For general information on medication errors and prevention:
Agency for Healthcare Research and Quality, ahrq.gov
American Society of Health-System Pharmacists, public website, safemedication.com
The Commonwealth Fund, cmwf.org
The Food and Drug Administration, Center for Drug Evaluation and Research, fda.gov
Institute for Safe Medication Practices, ismp.org
National Coordinating Council for Medication Error Reporting and Prevention, nccmerp.org
Source: hoinews.com |
