The needless deaths of a string of prized polo horses in South Florida has been determined to be the result of pharmacy error! Looking at the stats below for human pharmaceutical errors should we be surprised that a miscalculation by a compounding pharmacist would result in the death of animals given the “tainted” formula? This is one of the biggest problems with drug based therapies. How can you be sure the drug you were prescribed is the one that you are actually given?
One other consideration is the dependence of the sport horse community on “performance enhancers”. Just like the human sports world, talent doesn’t seem to be enough. Every trainer has their special blends of drugs and supplements supposed to make the horse a better athalete. What really happpens is the horses are injured younger and they have much shorter careers than in times past. We are breeding and training “flash in the pan” horses without the stamina and long term health to perform into their middle age, or even much beyond puberty.
My friend and trainer Ginny Padgett and I still have a dream of raising a healthy horse to run naturally and win. I think this goal is very obtainable. We just need to find a horse owner willing to “buck” the current system.
Medication Error Statistics
Medication errors are a
common occurrence and
continue to be a problem in
the health care industry. It
is estimated that the annual
cost of drug-related morbidity
and mortality is nearly
$177 billion in the United
States.
1
Approximately 7,000
deaths occur each year and
medication errors occur in just
about 1 of every 5 doses given
in hospitals.
2
The FDA states
that there is at least one death
per day and 1.3 million people
are injured each year due to
medication errors.
3
The National Coordinating
Council for Medication
Error (NCCMERP) defi nes a
medication error as being “any
preventable event that may
cause or lead to inappropriate
medication use or patient
harm, while the medication
is in the control of the health
care professional, patient or consumer.” Such events may be related to professional
practice, health care products, procedures and systems including: prescribing; order
communication; product labeling, packaging and nomenclature; compounding; dispensing;
distribution; administration; education monitoring; and use.
2
Common causes of medication errors include incorrect diagnosis, prescribing errors,
drug-drug related reactions, dose miscalculations, incorrect drug administration and lack of
patient education. Other factors that can contribute are job-related stress, improper training
or education and sound-alike look-alike packaging of medications.
3
did aal etPhillips J.
retrospective analysis of medication errors between 1993 – 1998 and found that the most
common types of errors were from administering improper dose (40.9%; 36.4% being
overdose), wrong drug (19%), and wrong route of administration (9.5%). The investigators
also found that the most common causes of errors were performance and knowledge
defi cits (44%) and communication errors (15.8%).
4
By Steven Morgan, Pharm.D. Pharmacy Practice Resident
ftjhthtdddscription
The
A Joint Publication from the University Health System Pharmacy Department, Risk Management and Ambulatory Services
Editor: Brandi Kelly, Pharm. D
