Fatal Medication Errors and Adverse Drug Reactions - Coroners’ Inquests and Other Sources

Fatal Medication Errors and Adverse Drug Reactions – Coroners’ Inquests and Other Sources

INTRODUCTION

Adverse drug events are harmful consequences from the therapeutic use of drugs. They include adverse consequences from reactions to drugs, adverse inter-actions between drugs and the harm that comes from medication errors. Some ambiguity arises from the term ‘adverse drug event’, as it is sometimes used to represent an adverse drug reaction (ADR).

The widely accepted definition of an ADR is ‘a response to a drug that is noxious and unintended and occurs at doses normally used in man for prophylaxis, diagnosis or therapy of disease, or for modification or physiological function’ (World Health Organiza-tion, 1972). Medication errors, i.e. errors in prescribing, drawing up and administering drugs, are a particularly important group of adverse drug events, because they are potentially preventable. The precise definition has proved difficult, but we have previously suggested the following: a medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient (Ferner and Aronson, 1999). ‘Failure’ in this context signifies that the process has fallen below some attainable standard. This definition carries the important implication that such failures could be avoided if the attainable standard were in fact attained. A corollary is that those ADRs that are categorised as ‘preventable’ represent medication errors.