Brianna A. da Silva|Mahesh Krishnamurthy
The alarming reality of medication error: a patient case and review of Pennsylvania and National data
Easton Hospital|Drexel University|Easton Hospital|Drexel University
71yearold female accidentally received thiothixene navane antipsychotic instead antihypertensive medication amlodipine norvasc 3 months sustained physical psychological harm including ambulatory dysfunction tremors mood swings personality changes despite many opportunities intervention multiple health care providers overlooked symptomserrors occurred multiple care levels including prescribing initial pharmacy dispensation hospitalization subsequent outpatient followup exemplifies swiss cheese model errors occur within system adverse drug events ades account 35 million physician office visits 1 million emergency department visits year believed preventable medication errors impact 7 million patients cost almost 21 billion annually across care settings 30 hospitalized patients least one discrepancy discharge medication reconciliation medication errors ades underreported burden adversely affects patients providers economymedication reconciliation including indication review prescription important aspect patient safety decreasing frequency pill bottle reviews suboptimal patient education poor communication healthcare providers factors threaten patient safety medication error ades cost billions health care dollars detrimental providerpatient relationship