PRESENTED BY:SHYAMU MANDAL

ANJU JOSHI

MEDICATION SAFETY

INTRODUCTION

Medication safety has long been recognized to be important in the provision of patient care. . With the evidence now pointing to medication errors as one of the leading causes of avoidable complications and deaths, there is a pressing need for a better understanding of the nature and scope of medication errors,and the will to improve the current clinical delivery systems.

Medication errors occur in all health care settings. Findings from several studies of large numbers of hospitalised patients indicated that each year many patients are harmed, injured or experienced adverse drug events as a result of medication errors.

DEFINATION OF MEDICATION ERROR

The term medication error has been defined in many ways. The US National Co-ordinating Council for Medication Error Reporting and Prevention defines it as:

“ any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer.”

Medication errors may be related to professional practice, products, procedures, environment or systems. They may involve prescribing and ordering; dispensing and distribution; preparation and administration; labelling, packaging and nomenclature; communications and education; or use and monitoring of treatment.

An adverse drug event is defined as an injury resulting from drug-related interventions. It can include prescribing errors, dispensing errors and medication administration errors. Adverse drug events are costly and result in significant additional health care resource consumption.

 

FACTS ABOUT MEDICATION ERRORS

Between 1993 and 1998, the US food and drug administration adverse event reporting system recorded 5307 medication error reports. The findings were: Medication errors were fatal in 9.8% cases. 48.6% of deaths occurred in patients greater than 60

years old. The three most common causes of death were

improper dose, wrong drug, and wrong route of administration; collectively these represented approximately 66% of all deaths assosiated with medication errors.

The institute of medicine reported that in the US, 7000 deaths occur yearly due to medication errors. Medication errors account for one out of 131

outpatient death and one out of 854 inpatient deaths.

Bates et al. reported that 42% of Adverse Drug Events were preventable and were caused by: Ordering errors(56%) Administration errors(34%) Transcription errors(6%) Dispensing errors(4%)

The medication use process includes:

1. Prescribing2. Dispensing3. Administering4. Monitoring of medicines.Note: these steps may be carried out by health-careworkers or the patient; e.g. self-prescribing over-

thecounter medication and self-administering

medication atHome.

Prescribing involves …

choosing an appropriate medication for a given clinical situation taking individual patient factors into account such as allergies

selecting the administration route, dose, time and regimen

communicating details of the plan with: whoever will administer the medication (written-

transcribing and/or verbal) and the patient

documentation

How can prescribing go wrong?

inadequate knowledge about drug indications and contraindications

not considering individual patient factors such as allergies, pregnancy, co-morbidities, other medications

wrong patient, wrong dose, wrong time, wrong drug, wrong route

inadequate communication (written, verbal)documentation - illegible, incomplete, ambiguousmathematical error when calculating dosage incorrect data entry when using computerized

prescribing e.g. duplication, omission, wrong number

SOME EXAMPLES OF PRESCRIBING ERRORS

Look-a-like and sound-a-like medications

Celebrex (an anti-inflammatory)Cerebryx (an anticonvulsant)Celexa (an antidepressant)

14

SAFER!...Make sure the decimal point is OBVIOUS!

Missing the point entirely!

A line may interfere with the observation of a decimal point. The order for 20.4 mg of Cisplatin (chemotherapy) was interpreted as 204 mg, resulting in a ten fold overdose and death.

15“U” is easily mistaken for “4” or “0”

An accident waiting (impatiently) to happen!!

60 units of insulin were given, not 6!!

SAFER!...WRITE OUT “UNITS”

BASIC PRINCIPLES OF PRESCRIBING SAFELY

1. Before prescribing: Assess the patient thoroughly, making sure the

drug is appropriate and not contraindicated . Always ask if the patient is allergic to any drugs;

if this is not already documented, write it down. Take into consideration any medication the patient

is already taking, checking there are no interactions .

2. When prescribing: Check that you are prescribing the correct

medication to the correct patient . Use generic drug names rather than brand

names. Don't use abbreviations. Check the dose, frequency, and route of

administration are correct and appropriate for the patient. Include a start date and a review date.

Avoid unnecessary zeros (for example, 1.0 mg), which may be misread, and make sure the units you use are correct.

If in doubt, refer to appropriate reference Make sure your prescription is legible and easy to

read. Explain what you are prescribing to the patient and

why; describing how and when to take medication increases compliance and reduces confusion.

3. After prescribing:

Watch out for any unprecedented reactions . Review the indications for the drug regularly. This

prevents patients from taking medications they don't need to take.

Dispensing involves…..

reviewing and processing the order, compounding/ preparation of the drug and dispensing the drug in a timely manner.

Source of error in dispensing

Basic principles of dispensing safely:

1. During processing of order (typing, picking and packing):

Interpret prescription carefully to identify any ambiguity or safety concerns.

Do not hesitate to contact prescriber for any illegible or ambiguous order.

Remind prescriber to avoid using dangerous abbreviations when detected on order.

Check that you are entering the correct order into the correct patient profile.

Do NOT ignore warnings or alerts on allergy, drug interactions, contra-indications when entering order into computer system.

Make sure drug label information contains the correct patient name, drug, strength, quantity, dosage instructions and cautionary instructions.

2. During dispensing: Check that you are dispensing the correct drug to

the correct patient. Always ask if patient is allergic to any drugs.

Take into consideration any medication the patient is already taking, including Traditional Chinese Medicine, so as to identify any potential drug-drug interactions.

Caution patient on possible food-drug interactions. Explain clearly to patient what is the drug for, how

and when should it be taken and what are the adverse drug reactions to look out for.

Keep up-to-date references, including on-line version, easily accessible for quick reference check when in doubt.

Administration involves …

obtaining the medication in a ready-to-use form; may involve counting, calculating, mixing, labeling or preparing in some way

checking for allergiesgiving the right medication to the right

patient, in the right dose, via the right route at the right time

Documentation.

How can drug administration go wrong?

wrong patientwrong routewrong timewrong dosewrong drugomission, failure to administerinadequate documentation

Basic principles of administering medication safely………..

1. Before administration: Check that you are taking the correct medication

chart for the correct patient. Interpret the order carefully before preparing drug

for administration. Check that the pharmacist has reviewed a new drug

order before administering. Check for any drug allergy or ambiguous order.

Do not hesitate to contact the prescriber for any illegible or ambiguous order.

Check that you are preparing the correct drug for the correct patient.

Always get a double-check for correct drug, dose, route and time of administration before administering the drug.

Be familiar with all the different administration sets and devices available in the inventory.

2. During administration: Check that you are administering the correct

drug to the correct patient. Advise patients on the possible adverse drug

reactions that they may experience during and after administration.

Encourage patient to express any discomfort or problems experienced during drug administration.

3. After administration: Document promptly on the medication chart the

time that the drug is administered.

Monitoring involves …

observing the patient to determine if the medication is working, being used appropriately and not harming the patient

Documentation.

How can monitoring go wrong?

lack of monitoring for side-effectsdrug not ceased if not working or course

completedrug ceased before course completeddrug levels not measured, or not followed up

oncommunication failures

Basic principles of monitoring medication use……

Be familiar with the drug use protocols Be familiar with the possible adverse drug reactions

following drug administration Be vigilant when monitoring patient by adhering strictly to

established protocols Alert prescriber promptly should patient develop unexpected

signs and symptoms or is not responding as expected Document patient’s response on the medication chart in a

timely manner Do not use dangerous abbreviations when documenting

administration details Keep up-to-date references easily accessible for quick checks

Which patients are most at risk of medication error?

patients on multiple medicationspatients with another condition, e.g. renal

impairment, pregnancypatients who cannot communicate wellpatients who have more than one doctorpatients who do not take an active role in

their own medication usechildren and babies (dose calculations

required)

In what situations are staff most likely to contribute to a medication error?

inexperiencerushingdoing two things at onceinterruptionsfatigue, boredom, being on “automatic

pilot” leading to failure to check and double-check

lack of checking and double checking habitspoor teamwork and/or communication

between colleaguesreluctance to use memory aids

How can workplace design contribute to medication errors?

absence of a safety culture in the workplace e.g. poor reporting systems and failure to learn from

past near misses and adverse eventsabsence of memory aids for staff inadequate staff numbers

Performance requirements

What you can do to make medication use safer: use generic names tailor prescribing for each patient learn and practise thorough medication history

taking know the high-risk medications and take precautions know the medications you prescribe well use memory aids communicate clearly develop checking habits encourage patients to be actively involved report and learn from errors

Tailor your prescribing for each individual patient

Consider: allergies co-morbidities (especially liver and renal

impairment) other medication pregnancy and breastfeeding size of patient

Know which medications are high risk and take precautions

narrow therapeutic window multiple interactions with other medications potent medications complex dosage and monitoring schedules examples:

oral anticoagulants Insulin chemotherapeutic agents neuromuscular blocking agents aminoglycoside antibiotics intravenous potassium emergency medications (potent and used in high pressure

situations)

Use memory aids

textbookspersonal digital assistantcomputer programmes, computerized

prescribingprotocolsfree up your brain for problem solving rather

than remembering facts and figures that can be stored elsewhere

looking things up if unsure is a marker of safe practice, not incompetence!

Remember the 5 Rs when prescribing and administering

Can you remember what they are?right drugright doseright routeright timeright patient

Communicate clearly

the 5 Rsstate the obviousclose the loop

Develop checking habits

when prescribing a medicationwhen administering medication:

check for allergies check the 5 Rs

remember computerized systems still require checking

always check and it will become a habit!

Encourage patients to be actively involved in the process

when prescribing a new medication provide patients with the following information: name, purpose and action of the medication dose, route and administration schedule special instructions, directions and precautions common side-effects and interactions how the medication will be monitored

encourage patients to keep a written record of their medications and allergies

encourage patients to present this information whenever they consult a doctor

Report and learn from medication errors

Summary

medications can greatly improve health when used wisely and correctly

yet, medication error is common and is causing preventable human suffering and financial cost

remember that using medications to help patients is not a risk-free activity

know your responsibilities and work hard to make medication use safe for your patients

Example case

a 74-year-old man sees a community doctor for treatment of new onset stable angina

the doctor has not met this patient before and takes a full past history and medication history

he discovers the patient has been healthy and only takes medication for headaches

the patient cannot recall the name of the headache medication

the doctor assumes it is an analgesic that the patient takes whenever he develops a headache

Example case

but the medication is actually a beta-blocker that he takes every day for migraine; this medication was prescribed by a different doctor

the doctor commences the patient on aspirin and another beta-blocker for the angina

after commencing the new medication, the patient develops bradycardia and postural hypotension

unfortunately the patient has a fall three days later due to dizziness on standing; he fractures his hip in the fall

What factors contributed to this medication error?

two drugs of the same class prescribed unknowingly with potentiation of side-effects

patient not well informed about his medicationspatient did not bring medication list with him

when consulting the doctordoctor did not do a thorough enough

medication historytwo doctors prescribing for one patientpatient may not have been warned of potential

side-effects and of what to do if side-effects occur

Case

a 38-year-old woman comes to the hospital with 20 minutes of itchy red rash and facial swelling; she has a history of serious allergic reactions

a nurse draws up 10 mls of 1:10,000 adrenaline (epinephrine) into a 10 ml syringe and leaves it at the bedside ready to use (1 mg in total) just in case the doctor requests it

meanwhile the doctor inserts an intravenous cannula

the doctor sees the 10 ml syringe of clear fluid that the nurse has drawn up and assumes it is normal saline

Casethere is no communication between the doctor

and the nurse at this timethe doctor gives all 10 mls of adrenaline

(epinephrine) through the intravenous cannula thinking he is using saline to flush the line.

the patient suddenly feels terrible, anxious, becomes tachycardic and then becomes unconscious with no pulse

she is discovered to be in ventricular tachycardia, is resuscitated and fortunately makes a good recovery

recommended dose of adrenaline (epinephrine) in anaphylaxis is 0.3 - 0.5 mg IM, this patient received 1mg IV

Can you identify the contributing factors to this error?

assumptionslack of communicationinadequate labeling of syringegiving a substance without checking and

double-checking what it islack of care with a potent medication

How could this error have been prevented?

never give a medication unless you are sure you know what it is; be suspicious of unlabelled syringes

never use an unlabelled syringe unless you have drawn the medication up yourself

label all syringescommunication - nurse and doctor to keep each

other informed of what they are doing e.g. nurse: “I’m drawing up some adrenaline”

develop checking habits before administering every medication … go through the 5 Rs e.g doctor: “ What is in this syringe?”

THANK YOU