Math/Tenfold Error in Drug Dosages
Quite often, we hear people around us mentioning the term tenfold error. This term is used whenever people refer to errors that can arise during the carrying out of activities such as prescribing dosages in a clinical environment. We can, therefore, define the term tenfold error as a type of error that has ten times variation from the true value. An example would be an error where a patient is given drugs ten tons the amount which was intended for the particular illness. This error can occur due to a number of reasons such as misreading of the dosage orders. A typical example is when a 10mg order is misread as the 100mg order. In such as case, the patient will end up taking a dose of drugs ten times more than required.
Tenfold error is the most severe form of error that can occur in health institutions especially in the administration of dosage orders by the hospital pharmacist attendants. This error is lethal as it can cause severe risks to patients. However, there are other forms of errors that can occur in a clinical environment though their effects may be less severe than that caused by the tenfold error. An error can arise in the packing of drugs especially those that can cause color blindness to the person packing them. However, such errors may not be as fatal as the tenfold error since the magnitude of the error may be slightly lower than that of the tenfold error. However, in all cases of errors, harmful effects can be experienced such as hospitalization of the affected patients.
In the first case of the scenario presented, we notice that the error resulted from a misreading of the dosage order where 'q' was interpreted as '0' thus making 110mg to be interpreted as 1110mg. Nevertheless, the nurse would have prevented this error from taking place before issuing the wrong dosage. This kind of errors would have necessitated the nurse to seek clarification from the doctor since a child of that age cannot take drugs of such dosage. Knowing this could have raised an alarm over the error and thus resolving it.
For the case depicted in the second scenario, the error that resulted was due to a misreading of the doctors prescription which had been written in an unprofessional manner. In this case, a prescription of 40mg/kg per day was misread as 400mg/kg per day. Such error would have been prevented by the nurse through carrying out routine double-checking of dosages. This would have meant that the error is identified before the patients get overdosed. Nurses should, therefore, be encouraged to check and verify dosages before administering in order ensure that they are consistent with the dosages that are provided in printed pediatric sheets.
While carrying out the calculation of dosages necessary to give to various patients, there are possibilities errors occurring which may lead to the dispensing of wrong dosage. In our case, When making the calculation of dosage we have often made a number of errors in the reading of dosage order due to poor representation of information by the doctors. For instance, some doctors instead of writing 'sliding scale' in full end up writing the abbreviation 'SS' to represent these words. This abbreviation has often confused us as it turns out to be similar to 55. In some other cases too, some doctors use the letter 'U' to denote unit or units and this sometimes turned out to be similar to '0'. As a result, orders with 4U have in some cases looked like '40'. All these errors have led to the wrong calculation of dosage information. Though the errors may be less severe than tenfold error, their effect can be felt by patients and thus potentially harmful.
Another common cause of the tenfold error has been when some doctors use decimal points in writing dosage orders. In such cases, the decimal points may be ignored by mistake or it may fail to be seen when reading the dosages. For instance, a dosage order written as 10.0mg may be misread as 100mg, ten times the required dosage. To address this error, doctors should be discouraged from using decimal points in writing orders. Through such measures, the severity of errors can be lessened thus ensuring that correct dosage is provided as required.