Preventing MEDICATION ERRORS

in the ICU

CHARLENE TAY Clinical Pharmacy

Kuala Lumpur General Hospital

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OUTLINE

Medication Error Defined

Errors in ICU

Contributory Factors

Types of Errors

Strategies & Safe Practices

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PATIENT SAFETY, A COMMON GOAL

Patient safety is an attempt to assure that a course of medical treatment

will proceed correctly and provide the best possible chance to achieve

the desired outcome

Freedom from healthcare associated, preventable harm

Major issue of patient safety is Medical Errors – 3rd leading cause of

death

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MEDICATION ERROR

Commonest medical errors reported within hospitals

ME defined as;

Any preventable event that may cause or lead to inappropriate

medication use or patient harm (National Coordinating Council for Medication Error Reporting & Prevention NCC MERP)

Increase in the duration of hospitalization and disability & death in up to

6.5% of hospital admissions

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CRITICAL CARE SETTING

Enhanced vulnerability of patient

o Reduced physiological reserve,

o Reduced metabolic ability,

o Pharmacokinetics alterations

Nature of treatment

o Multiple drugs

o Use of Dangerous Drugs / high risk substances

o Variable routes of administration

Environment

o Busy, hurried

o Highly pressured

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WHERE DO

ERRORS OCCUR?

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CONTRIBUTING FACTORS

Unavailable / insufficient patient information (not knowing about patients'

allergies, drug contraindications, diagnoses, and lab values)

Poorly written prescriptions & miscommunication of drug orders

Problems with labelling, packaging and drug nomenclature

Drug standardization, storage, and stocking (eg multiple strength of the same

drug)

Drug device acquisition, use and monitoring

Environmental stress (factors such as lighting, heat, noise, and interruptions)

Limited staff education (lack of awareness of error-prone situations go

unidentified and persist in causing problems)

Lack of quality improvement processes and risk management 7

American Hospital Association, 2015

LOCAL TRENDS & STATISTICS

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Year No of

errors

No of errors

in ICU

2015 20999 63

2016 19923 46

2017 26056 193

Medication Errors Reporting System (MERS), MOH

85%

15%

Near Misses Actual Error

2017

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Contributing

Factor n % Contributing Factor n %

Staff Factors 138 51.3

Inexperienced personnel 79 29.4%

Inadequate knowledge 41 15.2%

Distraction 18 6.7%

Medication

Related 3 1.1

Sound alike medication 2 0.7%

Look alike medication 0 0.0%

Look alike packaging 1 0.4%

Task &

Technology 59 21.9

Failure to adhere to work procedure 55 20.4%

Use of abbreviations 0 0.0%

Illegible prescription 2 0.7%

Patient information/record/ unavailable/

inaccurate 0

0.0%

Wrong labelling/ instruction on dispensing

envelope or bottle/ container 0

0.0%

Incorrect computer entry 2 0.7%

Work &

Environment 68 25.3

Heavy workload 37 13.8%

Peak hour 31 11.5%

Stock arrangements/ storage problem 0 0.0%

Others 1 0.4 Others 1 0.4%

Total 269 100.0 Total 269 100.0

Medication Errors Reporting System (MERS), MOH

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PREVENTIVE STRATEGIES

STRATEGIES TO PREVENT ERRORS:

PRESCRIPTIONS

Clear handwriting (eg upper-case, readable cursive).

Doses written using metric system

Use standard abbreviations

Write drug names in full (eg: KCl, CPZ, CBZ)

Use a leading zero if a number is less than one

(0.1), and avoid a trailing zero after a decimal

(5.0).

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STRATEGIES TO PREVENT ERRORS: DISPENSING & SUPPLY

Processing Prescriptions

Screening, Interpreting, Enquiring

Preparation

Filling, Compounding, Labelling,

Checking

Counter Checking

Recording

Issuing Medication

5R : Patient ; Medicine; Dose;

Route; Time 2009 LIMYS INTRO,IMPACT,CAUSES,TYPES,PREVENTION 13

STRATEGIES TO PREVENT ERRORS: PREPARATION

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Drug Supply

1st Counter – check

PREPARATION

2nd Counter - check

Administration

• Determine appropriate route

• Single dose ampoules or

multidose vials?

• Reconstitution & dilution

compatibility

• Correct volume; solution

concentration

• Inspection – appearance,

particles, crystallisation

• Technical issues : safe use &

disposal of sharps

• Good infection control practice

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Prescribed : IVI Pantoprazole 8mg/hr

Final drug concentration: 2mg/ml

Infusion rate : 2ml/hr

Actual dose administered : 4mg/hr

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STRATEGIES TO PREVENT ERRORS: ADMINISTRATION

‘not solely a mechanistic task to be performed in strict compliance

with the written prescription of a medical practitioner. It requires

thought and exercise of professional judgement’ (NMC, 2002)

RIGHT PERSON

Checking name on prescription

order & patient board/ID tags

Use 2 patient identifiers –

name &

identification/registration

number

Highlight patients with similar

names

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Name: ABCDE

MRN: 12345

Admission: 06.05.15

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RIGHT

MEDICATION

Drug indication

Sound similar – look alike drugs

o Conventional vs Lipid Complex

Amphotercin B

o Noradrenaline vs Dobutamine

RIGHT DOSE & TIME

Administration of medication at the correct

time interval

Administration of medication within (not > 30

mins) the predefined interval

Avoid serving multiple drug of the same group at

the same intervals (eg antihypertensives) 19

Preparing & serving exact dose ordered (eg: freshly prepared items)

Check appropriateness of dose

Injectables are administered at a suitable rate

o IV Azithromycin over 1 hour; IV Vitamin K 1mg/min (eg antihypertensives)

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i. Check patency of route

ii. Central vs Peripheral Line

Highly concentrated drugs

Inotropes / Vasopressors

Antineoplastic agents

TPN

Acidic or highly alkaline

products

↑ Risk of extravasation

Irritation to

venous

endothelium

& wall

RIGHT ROUTE

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MANIPULATING FORMULATIONS ?

Considerations :

PO or Nasogastric (NG) tubes, nasojejunal (NJ) tubes

Nature of tablet/capsule : EX, SR, Enteric coated, Film coated

Examples :

X Sodium Valproate (enteric coated tablet), Theophylline SR & IR,

Oxycontin (SR) tablets, Akurit – 4

DOCUMENTATION,

REASON &

RESPONSE

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• Document administration after giving

ordered medication

• Check rationale of the ordered

medication & its desired effect

HIGH ALERT MEDICATIONS (HAM)

Medications with very narrow

margin of safety

Heightened risk of causing severe

patient harm when implicated in an

adverse drug event

HAM should be prescribed, packed,

stored, and administered differently

than others – ISMP

19 categories, 14 specific drugs listed

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CLASSES / CATEGORIES

OF HAM

LOOK ALIKE – SOUND ALIKE (LASA)

In 2001, 5003 near miss errors –

6% associated with LASA

Visually similar in physical

appearance or packaging

Names that have spelling

similarities and/or similar

phonetics.

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LOOK-ALIKE & SOUND-ALIKE MEDICATIONS (BY STRENGTH)

1. Acitretin 10mg, 25mg Capsule

2. Alfacalcidol 0.25mcg,1mg Capsule

3. Allopurinol 100mg, 300mg Tablet

4. Rifampicin/ Isoniazid (Akurit-2®), Rifampicin/ Isoniazid /Ethambutol/ Pyrazinamide (Akurit-4®) Tablet

5. Amisulpiride 100mg & 400mg Tablet

6. Aripiprazole 10mg,15mg Tablet

7. Aqueous in 25% Glycerin, Aqueous in 50% Glycerin

8. Amlodipine 5mg, 10mg Tablet

9. Amphotericin 0.15%, 0.3% Eye Drop

10. Irbesartan (Aprovel®) 150mg, 300mg Tablet

11. Atenolol 50mg, 100mg Tablet

12. Atomoxetine HCL 18mg, 25mg, 40mg, 60mg Capsule

13. Betamethasone 17-Valerate 0.01%, 0.025%, 0.05%, 0.1% cream

14. Betamethasone 17-Valerate 0.01%, 0.025%, 0.05%, 0.1% ointment

15. Bisoprolol 2.5mg, 5mg Tablet

16. Benzyl Benzoate 12.5%, 25% emulsion

17. Carbamazepine CR 200mg, 400mg Tablet

18. Carvedilol 6.25mg, 25mg Tablet

19. Ceftazidime 1g, 2g Injection

1. Cefuroxime 750mg, 1.5g Injection

2. Chlorpromazine HCL 25mg, 100mg Tablet

3. Cholecalciferol 400iu, 1000iu Tablet

4. Ciclosporin 25mg, 100mg Capsule

5. Ciclosporin 0.05%, 0.5%, 1% Eye Drop

6. Clozapine 25mg & 100mg Tablet

7. Coal Tar (Liquor Picis Carbonis @ LPC) 1%, 3%, 6%, 9% ointment

8. Coal Tar (Liquor Picis Carbonis @ LPC) 1%, 3%, 6%, 9% ointment & Salicylic acid 2% ointment

9. Irbesartan/ Hydrochlorothiazide (Co-Aprovel® 150/12.5mg , 300/12.5mg Tablet

10. Amlodipine/ Losartan (Cozaar XQ®) 5mg/50mg , 5mg/100mg Tablet

11. Dabigatran Etexilate 110mg, 150mg Capsule

12. Desmopressin 0.1mg, 0.2mg Tablet

13. Donepezil orodispersible Tablet (Aripcet Evess) 5mg, 10mg

14. Duloxetine 30mg, 60mg Capsule

15. Enoxaparin Sodium 20mg , 40mg, 60mg Injection

16. Erythropoietin Human Recombinant (Alfa) 2000IU, 4000IU, 10,000IU Injection (Eprex)

17. Erythropoietin Human Recombinant (Beta) 2,000IU, 4000IU Injection (Recormon)

MANAGING HAM

“HIGH ALERT MEDICATION” labels on storage

shelves, containers, product packages and loose vials

or ampoules. kept in individual labeled containers

All diluted medications labelled with the name

and strength immediately upon dilution

Avoid verbal orders . In cases of emergency,

phone orders have to be repeated and verified.

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MANAGING LASA

TALL-man lettering to emphasize differences in medication names (e.g.

DOPAmine vs DOBUtamine)

Additional warning labels – storage, emergency trolleys.

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MANAGING LASA

Avoid storing LASA products in immediate proximity

Accessibility to LASA list & all personnel should be informed of updates

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REPORTING ERRORS

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Number of reported drug errors is the „tip of the iceberg‟

Deterrents : management reprisal and the reaction

Opportunity to identify and rectify defective systems Implement a culture of patient safety in the system

THANK YOU

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