Medication errors: pharmacovigilance centres in detection and prevention

Abstract

1. Detecting medication errors needs collaboration between various organizations, such as patient safety institutions, pharmacovigilance centres, and poison control centres. In order to evaluate the input of pharmacovigilance centres and poison control centres in detecting and evaluating medication errors a pilot project was initiated by the World Alliance for Patient Safety in collaboration with the Uppsala Monitoring Centre; the Moroccan pharmacovigilance centre acted as project coordinator. As part of this project, a questionnaire on detecting medication errors was circulated to pharmacovigilance centres and poison control centres around the world, in order to assess their ability to detect and analyse medication errors. 2. The results showed that through their databases pharmacovigilance centres can detect, identify, analyse, and classify medication errors and carry out root cause analysis, which is an important tool in preventing medication errors. 3. The duties of pharmacovigilance centres in preventing medication errors include informing health-care professionals about the importance of reporting such errors and creating a culture of patient safety. Pharmacovigilance centres aim to prevent medication errors in collaboration with poison control centres. Such collaboration allows improved detection and improved preventive strategies. In addition, collaboration with regulatory authorities is important in finalizing decisions. 4. Collaboration between pharmacovigilance centres and poison control centres should be strengthened and bridges need to be built linking pharmacovigilance centres, poison control centres, and organizations dedicated to patient safety, in order to avoid duplication of workload.

Current status of pharmacovigilance regulatory structures, processes, and outcomes in the Asia‐Pacific region: Survey results from 15 countries

“…It is important to manage, using national statistics, the percentage of therapeutic ineffectiveness and medication errors. A study conducted in Morocco found that PV centers can contribute to the detection and prevention of medication errors . As therapeutic ineffectiveness—unexpected or unexplained—is hypothetically an important reportable event in PV, observations of unexpected ineffectiveness in patients can provide crucial information …”

Inadvertent oral administration of methylergometrine maleate to children in the first months of life: from surveillance to prevention

“…Toxic effects due to oral administration to children in the first week of life of uterotonic ergot alkaloid had been documented in only two previous reports: a case of poisoning observed in Italy in 1985; a review of 34 cases of oral exposure handled by the Belgian Poison Control Centre between 1969 and 1999, including 9 children aged <1 month presenting with low severity effects and a 15‐day‐old female baby who developed severe clinical toxicity . In 2009, a retrospective analysis of the Moroccan Pharmacovigilance Centre database highlighted that one of the most frequent medication errors occurring in that country was administration of methylergometrine maleate to the wrong patients, mainly due to confusing prescription …”

Medication errors: EMERGing solutions

“…Simpler and cheaper methods are available and should be widely implemented. For example, error reporting is important in both detection and prevention [7], and pharmacovigilance has a role to play [13]. However, chief among the preventive methods is education [14].…”