Key Terms
Addiction
compulsive and uncontrollable use of a drug substance for reasons other than prescribed
Contaminated product error
when aseptic technique is not followed in compounding, and the drug is no longer sterile and causes a microorganism infection
Extra dose error
an error in which more doses are received by a patient than were prescribed by the physician
iPLEDGE program
a specific risk assessment program to prevent exposure to isotretinoin, which can cause a high incidence of birth defects if not properly monitored
MEDMARX
an Internet-based program of the USP for use by hospitals and healthcare systems for documenting, tracking, and identifying trends for adverse events and medication errors
Adverse drug error
occurs when the prescribed drug initiates an allergy or an adverse drug interaction flag that was missed
Distraction error
occurs when a technician or pharmacist is interrupted in the middle of a filling process and forgets a portion of key information or train of thought, and some information or a safety decision gets missed
Fear error
occurs when a technician fears the consequences of speaking up and asking the pharmacist or the prescriber to double-check an element of the prescription
MedGuide
printed information in which the FDA communicates side effects, adverse reactions, and black-box warnings for high-risk drugs
MedWatch
a voluntary program by the FDA that allows any healthcare professional or consumer to report a serious adverse event associated with the use of any drug, biologic device, or dietary supplement
Adverse drug reaction (ADR)
a negative consequence to a patient from taking a particular drug, due to the nature of the drug itself, for certain vulnerable populations
Documentation error
when essential information is not properly noted, such as a prescription, allergy, patient request, or other information in the medication profile, or not properly processing insurance or billing
Human failure
an error generated by failure that occurs at an individual level
Medication education error
when the proper medication education materials and counsel are not passed on to the patient or medication administrator
Mislabeling error
when a medication has incorrect information on it leading to the wrong use of it, or the wrong patient receiving it
Alert fatigue
where the technician and/or the pharmacist starts to have a relaxed attitude and bypasses drug utilization warnings
Drug seeker
a patient who is dependent on or addicted to drugs, who may receive prescriptions for the same or similar controlled drugs from several physicians and pharmacies
Incomplete information error
occurs when full information is not available because the patient was not asked sufficient or proper questions, or the answers were somehow not recorded in the profile, or the patient withheld information deliberately or by accident of memory
Medication error
any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer
Omission error
an administration error in which a prescribed dose is not given
Capture error
an error that occurs when focus on a task is diverted elsewhere and, therefore, the error goes undetected
Drug tolerance
when the body adapts to a drug so that higher doses are needed to produce the same pharmacological effect
Incorrect assumption error
occurs when an essential piece of information cannot be verified, and an assumption is made
Medication noncompliance
failure to take medication therapy as the physician instructs; also called nonadherence
Patient Safety Organizations (PSOs)
groups designed to collect and analyze error data from more than one health provider and offer quality improvement counsel