Case Study Medical Error
A Venn diagram showing the relation among adverse events, ADRs and medication errors; the sizes of the boxes do not reflect the relative frequencies of the events illustrated (Reproduced from reference 8, with permission from Wolters Kluwer Health/Adis ©; Adis Data Information BV (2006); all rights reserved).); of those that are detected a minority actually result in ADRs, or at least serious ones.
In 2000, an expert group on learning from adverse events in the NHS, chaired by the Chief Medical Officer, reported that since 1985 there had been at least 13 episodes in which people (usually children) had been killed or paralysed because of wrong administration of drugs by spinal injection; 12 involved vinca alkaloids; 10 were fatal.
All those who deal with medicines should establish or be familiar with such standards.
They should institute or observe measures to ensure that failure to meet the standards does not occur or is unlikely.
Everybody involved in the treatment process is responsible for their part of the process.
An adverse event is ‘any abnormal sign, symptom or laboratory test, or any syndromic combination of such abnormalities, any untoward or unplanned occurrence (e.g.