Medication errors remain an important cause of patient morbidity and mortality. Although
all medications have the potential to induce unwanted adverse effects, data on the
actual incidence and overall severity of preventable adverse drug reactions remains
unknown. An Institute of Medicine report (Institute of Medicine. Preventing medication
errors: Quality chasm series. Washington DC, National Academies Press. 2007-06-15)
estimated that 1.5 million preventable adverse drug events occur annually in the US
and that from 44,000 to 98,000 individuals die in hospitals annually from preventable
medication errors. The types of medication errors of clinical relevance leading to
moderate to severe outcomes are unfortunately numerous. Such errors would include
wrong drug, wrong dose / wrong dose interval and represent the more serious form of
a medication error. Institutionalized patients and those patients cared for in long-term
care facilities appear to be at heightened risk for a medication error. These patients
often receive multiple medications and suffer from variable degrees of cognitive impairment
which complicates or negates patient-caregiver communication, one of the most important
means to prevent medication errors. Moreover, the increasing financial constraints
placed upon treatment facilities encourage the use of generic, rather than name brand
medications by their pharmacy provider. While the use of bioequivalent generic medications
is completely appropriate and can be very cost-effective, generic drug manufacturers
are less often manufacturing their generic medications to look like the name brand
drug. Rather, more and more generic medications are plain appearing with no resemblance
whatsoever to the name brand product. This difference in drug appearance between the
generic and the brand name product as well as differences in drug appearance between
different generic drug manufacturers for the same medication represents another, important
means by which patients may experience moderate to serious consequences from a medication
error. We report such an experience where a patient in a long-term care facility received
multi-day, excessive dosing of glipizide rather than her anti-spasticity medication,
baclofen.
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© 2007 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.