Medication Safety & Medication Errors
Part I
PHCL 311
Medication Safety & Medication Errors
Part I
PHCL 311
Hadeel Al-Kofide MS.c
Topics to be covered todayTopics to be covered today
• Introduction
• The evidence that medication error is a problem
• Definitions
• The relationship between medication error, ADE & ADE
• Classifications & types of medication error
• Reasons for medication errors
• How to prevent medication error
IntroductionIntroduction
• The goal of drug therapy is the achievement of defined therapeutic outcomes that improve a patient’s quality of life while minimizing patient risk
• With every therapy there must be a risk, it could be known or unknown
• These risks are defined as drug misadventures, which includes both adverse drug reactions (ADRs) & medication errors
DefinitionsDefinitions
• Medication error
• Adverse drug event (ADE)
• Adverse drug reaction (ADR)
Adverse Drug Events (ADE)Adverse Drug Events (ADE)
• Any injury caused by a medicine or lack of intended
medication
Adverse drug reactions & overdoses
Dose reductions & discontinuations of drug therapy
Definitions
Adverse Drug Reaction (ADR)Adverse Drug Reaction (ADR)
• Any unexpected, unintended, undesired, or excessive response
to a drug, with or without an “injury”
• Harm directly caused by the drug at normal doses,
during normal use
Definitions
Medication Error (ME)Medication Error (ME)
• Any preventable event that has the potential to lead to
inappropriate medication use or patient harm during
prescribing, transcribing, dispensing, administering,
adherence, or monitoring a drug
• Medication errors that are stopped before harm can occur are
sometimes called “near misses” or more formally,
a potential adverse drug event
Definitions
The Relationship Among ME, ADEs, & ADRs
The Relationship Among ME, ADEs, & ADRs
Medication Errors ADEs
ADRs
Nebecker et al. Ann Intern Med 2004;140: 795-801, J Gen Med 10:199-205,1995.
What Is The Evidence That Patient Safety Is A Problem?
What Is The Evidence That Patient Safety Is A Problem?
Evidence That ME is A ProblemEvidence That ME is A Problem
• Medications harm at least 1.5 million people per year
• 44,000 to 98,000 hospitalized Americans die each year from
medical error
• Errors cause more death each year than breast cancer, motor
vehicle accidents & AIDS
Institute of Medicine. Preventing medication errors: quality chasm series, 2006
ME is A Problem
Evidence That ME is A ProblemEvidence That ME is A Problem
• The financial burden from these medical errors that is
estimated to be in a range of $30 billion to $130 billion
annually
• Up to 28% of these events are thought to be preventable
White TJ et al, Pharmacoeconomic. 1999, Classen DC et al, JAMA. 1997
ME is A Problem
Phillips DP. Annu Rev Public Health. 2002;23:135-50.
Deaths from Medication Errors
1983 1998
Medication Error Deaths IncreasingMedication Error Deaths IncreasingME is A Problem
Types & Classification of Medication Errors
Types & Classification of Medication Errors
Types & Classification of METypes & Classification of ME
• NCC MERP index for categorizing medication errors
• Medication use process
• Three major areas for medication error:
Prescribing
Dispensing
Administration
NCC MERP Index for Categorizing ErrorsNCC MERP Index for Categorizing Errors
Medication Safety & Medication Errors
Part II
PHCL 311
Medication Safety & Medication Errors
Part II
PHCL 311
Hadeel Al-Kofide MS.c
Topics to be covered last lectureTopics to be covered last lecture
• Introduction
• The evidence that medication error is a problem
• Definitions
• The relationship between medication error, ADE & ADE
• Classifications & types of medication error
• Reasons for medication errors
• How to prevent medication error
Topics to be covered todayTopics to be covered today
• Focusing on error prevention
• Identifying medication error
• How to approach error (Person Vs. System)
• Methods used to minimize or reduce medication errors
• Establishing a culture of safety (Building a safer healthcare system )
• Medication error reporting system
The Medication Use System The Medication Use System
Selection & ProcuringEstablish formulary
Monitoring Assess patient response to drug; report reactions & errors
AdministeringReview dispensed drug order; assess patient & administer
Preparing & DispensingPurchase & store drug; review & confirm order; distribute to patient location
PrescribingAssess patient; determine need for drug therapy; select & order drug
High-Level Portrayal of a Medication Use System
Clinician & administrators
Physician/ prescriber
Pharmacist Nurse/other health professionals
All practitioners, plus patient &/or family
Joint Commission. 1998
Major Areas for Medication ErrorMajor Areas for Medication Error
• Medication errors can be broadly classified as
Prescribing
Dispensing
Drug administering errors
Major Areas for Medication ErrorMajor Areas for Medication Error
38% 39%
12% 11%
Medication Errors Reporting Program US
Prescribing Errors Prescribing Errors
• It is an incorrect drug selection for a patient. Such errors can include the dose, strength, route, quantity, indication, or prescribing contraindicated drug
• This definition can be further expanded to include failure to comply with legal requirements for prescription writing
Williams DJ. 2007, Lesar et al. JAMA. 1997
Types of ME
Prescribing ErrorsPrescribing Errors
Contributing factors:
• Illegible handwriting
• Inaccurate medication history taking
• Confusion with the drug name
• Inappropriate use of decimal points
• Use of abbreviations (e.g. AZT has led to confusion between Zidovudine & Azathioprine)
• Use of verbal order
Williams DJ. 2007
Types of ME
Prescribing Errors….. Examples Prescribing Errors….. Examples
Name That Drug…
Lipitor 10mg PO QD
Filled Rx: Zyrtec 10mg
Prescribing Errors….. Examples Prescribing Errors….. Examples
6 unties of regular insulin now
Name That Drug…
Filled Rx: 60 units
Prescribing Errors….. Examples Prescribing Errors….. Examples
Tegretol 300mg BID
Name That Drug…
Filled Rx: Tegretol 1300mg
Prescribing Errors….. Examples Prescribing Errors….. Examples
Cardura 2mg PO HS & Avandia 4mg PO QAM
Name That Drug…
Filled Rx: Coumadin 2mg PO HS & Coumadin 4mg PO QAM
Patient received 6mg of Coumadin PLUS no treatment for hypertension & diabetes
Prescribing Errors…..ExamplesPrescribing Errors…..Examples
Sometimes the technology itself is the problem…
Monopril 40mg
Filled Rx: Monopril 10mg
Dispensing ErrorsDispensing Errors
• It is an error that occurs at any stage during the dispensing process from the receipt of a prescription in the pharmacy through to the supply of a dispensed product to the patient
• Studies have estimated that dispensing errors occur at a rate of 1-24%
• These errors include the selection of the wrong strength/product. This occurs primarily when ≥ 2 drugs have a similar appearance or similar name (look-a-like/sound-a-like errors)
Dispensing Errors…..ExamplesDispensing Errors…..Examples
Dispensing Errors…..Examples Dispensing Errors…..Examples
Dispensing Errors…..Examples Dispensing Errors…..Examples
Dispensing Errors…..ExamplesDispensing Errors…..Examples
Rx AXERT (almotriptan) 6.25 mg 1-2 tablets at once, & repeat in 2 hours if needed up to 25 mg/day
Dispensed ANTIVERT (meclizine)
Dispensing Errors…..ExamplesDispensing Errors…..Examples
Rx Keppra (anticonvulsant) 500 mg every 12hours
Dispensed Kaletra (antiviral)
Administration Errors Administration Errors
• Defined as a discrepancy between the drug therapy received by the patient & the drug therapy intended by the prescriber
• Drug administration is associated with one of the highest risk areas in nursing practice
Administration Errors Administration Errors
• Drug administration errors largely involve errors of omission where administration is omitted due to a variety of factors e.g. wrong patient, lack of stock
• Other types of drug administration errors include wrong administration technique, administration of expired drugs & wrong preparation administered
Administration ErrorsAdministration Errors
Contributing factors:
• Failure to check the patient’s identity prior to administration
• Storage of similar preparations in similar areas
• Noise, interruptions while undertaking a drug round, & poor
lighting
• Errors
Williams DJ. 2007
• More than one tablet for a single dose• Calculation is required to determine the correct dose
Administration Errors…..ExamplesAdministration Errors…..Examples
A patient had an epidural line for pain management & a peripheral IV line containing insulin
The nurse caring for the patient was busy & asked a second
nurse to retrieve the next scheduled epidural infusion bag
The second nurse delivered a new bag of insulin to the
patient’s bedside
Without checking the label, the primary nurse hung the insulin
infusion to the epidural line
Reasons For Medication ErrorsReasons For Medication Errors
1. Ambiguous strength designated on labels or in packaging
2. Drug product nomenclature (look-alike or sound-alike names, use of lettered or numbered prefixes & suffixes in drug name)
3. Equipment failure or malfunction
4. Illegible writing
5. Improper transcription & inaccurate dosage calculation
6. Inadequately trained personnel
7. Inappropriate abbreviations
8. Labeling errors
9. Excessive workload
10. Lapses in individual performance
11. Medication unavailable
Focusing on Error PreventionFocusing on Error Prevention
Can We Do Anything About These Errors?
Can We Do Anything About These Errors?
Step One See the problem
Can We Do Anything About These Errors?
Can We Do Anything About These Errors?
Step Two
Identify
The Risk
& Manage It
Identifying Medication ErrorIdentifying Medication Error
How Can We Identify The Risk?How Can We Identify The Risk?
• High alert medication
• Error prone notations
• Look-a-like & sound-a-like medications
High Alert MedicationsHigh Alert Medications
• What are high alert medications?
• How can we reduce the error associated with high alert medications?
"Top 10" Medications Involved in Drug Errors
"Top 10" Medications Involved in Drug Errors
Agent % of Drug Errors Associated with
Acute Hospital Care
Insulin 4% of all medication errors in 2005
Morphine 2.3%
Potassium Chloride 2.2%
Albuterol 1.8%
Heparin 1.7%
United States Pharmacopeia.2007
High Alert Medications
"Top 10" Medications Involved in Drug Errors
"Top 10" Medications Involved in Drug Errors
Agent % of Drug Errors Associated with
Acute Hospital Care
Vancomycin 1.6%
Cefazolin 1.6%
Acetaminophen 1.6%
Warfarin 1.4%
Furosemide 1.4%
United States Pharmacopeia.2007
High Alert Medications
Strategies To Reduce Risk From High-Alert Medications
Strategies To Reduce Risk From High-Alert Medications
• Limit the access to these medications
• Standardizing the ordering/preparation & administration
• Independent double check at dispensing & administrating phase
High Alert Medications
Error-Prone NotationsError-Prone Notations
• Ambiguous medical notations are one of the most common & preventable causes of medication errors
• Misinterpretation may lead to mistakes that result in patient harm
• Delay start of therapy due to time spent for clarification
Implement “Do Not Use” ListImplement “Do Not Use” List
• ISMP & FDA recommend that ISMP’s list of error-prone abbreviations be considered whenever medical information is communicated
ISMP= Institute for Safe Medication Practices, FDA= Food and Drug Administration
Complete list is located at:
www.ismp.org/Tools/errorproneabbreviations.pdf
Error Prone Notations
Short List of Error-Prone Notations*Short List of Error-Prone Notations*
** Comprises “Do Not Use” list required for JCAHO accreditation Comprises “Do Not Use” list required for JCAHO accreditation
Notations should NEVER be usedNotations should NEVER be used
Notation Reason Instead Use
U Mistaken for 0, 4, cc Unit
IU Mistaken for IV or 10 Unit
QD Mistaken for QID Daily
QOD Mistaken for QID, QD “every other day”
Error Prone Notations
Short List of Error-Prone Notations*Short List of Error-Prone Notations*
** Comprises “Do Not Use” list required for JCAHO accreditation Comprises “Do Not Use” list required for JCAHO accreditation
Notations should NEVER be usedNotations should NEVER be used
Notation Reason Instead Use
Trailing zero
(X.0 mg)
Decimal point missed “X mg”
Naked decimal
Point (.X mg)
Decimal point missed “0.X mg”
cc Mistaken for U “mL”
MS Can mean Morphine Sulfate
or Magnesium Sulfate
“Morphine Sulfate”
Error Prone Notations
Short List of Error-Prone Notations*Short List of Error-Prone Notations*
** Comprises “Do Not Use” list required for JCAHO accreditation Comprises “Do Not Use” list required for JCAHO accreditation
Notations should NEVER be usedNotations should NEVER be used
Notation Reason Instead Use
> or < Mistaken as opposite of
intended
“greater than” or
“less than”
μ Mistaken for mg “mcg”
@ Mistaken for 2 “at”
/ Mistaken for 1 “per”
Error Prone Notations
Short List of Error-Prone Notations*Short List of Error-Prone Notations*
** Comprises “Do Not Use” list required for JCAHO accreditation Comprises “Do Not Use” list required for JCAHO accreditation
Notations should NEVER be usedNotations should NEVER be used
Notation Reason Instead Use
+ Mistaken for 4 “and”
D/C, dc, d/c Misinterpreted as when Misinterpreted as when
“discontinued” followed by “discontinued” followed by
list of medicationslist of medications
“discharge”
or
“discontinued”
Error Prone Notations
Error-Prone Notations…..Examples Error-Prone Notations…..Examples
Intended dose of 4 units
Administered 44 units
Should be written as “4 units”
Error Prone Notations
Error-Prone Notations…..Examples Error-Prone Notations…..Examples
Administered 4mg
Should be written as “0.4 mg.”
Intended dose of “.4 mg”
Error Prone Notations
Strategies To Reduce The Risk From Error Prone Notations
Strategies To Reduce The Risk From Error Prone Notations
• NEVER use notations
Error Prone Notations
Approaches to Reduce Medication Errors
Approaches to Reduce Medication Errors
Approaches to Reduce Medication Errors
Approaches to Reduce Medication Errors
• Person-centered approach
• System centered approach
• The Swiss cheese model of systems errors
Approaches to Reduce Medication Errors
Approaches to Reduce Medication Errors
Person-Centered Approach
• It has been traditional used in analysis of medication errors
• It looks at medication errors as occurring due to human frailty, including
Forgetfulness
Poor motivation
Carelessness, not paying attention
Negligence
Approaches to Reduce Medication Errors
Approaches to Reduce Medication Errors
System-Centered Approach
• Errors expected to occur
• Errors are viewed as the end result & not the cause
• There is potential for error & recurring errors in every system, & even the best systems fail
Approaches to Reduce Medication Errors
Approaches to Reduce Medication Errors
System-Centered Approach
• Solutions are based on the belief that conditions can be changed, rather than focusing on changing humans
• Barriers & safeguards should be implemented to help prevent errors
• It is essential to focus on how & why the system failed & not on which individual failed
Methods Used to Minimize or Reduce Medication Errors
Methods Used to Minimize or Reduce Medication Errors
Reducing Medication ErrorReducing Medication Error
• Steps to minimize medication error
• Prescriber actions
• Pharmacy (dispensing) actions
• Nurse (administrator) actions
Steps to Minimize Medication ErrorSteps to Minimize Medication Error
Mosteffective
Leasteffective
Steps to Minimize Medication ErrorSteps to Minimize Medication Error
Forcing functions & constraints
• Use pharmacy system that will not fill any order unless allergy information, patient weight & height are entered
• Use computer order entry with dosage checks
• Remove dangerous IV drugs (e.g. conc. potassium, hypertonic sodium chloride) from ward stock
• Limit choices of available drugs in pharmacy
• Limit dosage strengths & concentration for each drug
• Mix IVs in the pharmacy
Steps to Minimize Medication ErrorSteps to Minimize Medication Error
Automation & computerization (Reduce reliance on memory)
• Use drug-drug interaction checking system
• Use computerized order entry
• Use computerized patient information
• Use bar-coding on drugs, containers, medication records, patient wristbands
• Automated dispensing on patient care unit
Steps to Minimize Medication ErrorSteps to Minimize Medication Error
Standardization & protocol
• No error –prone abbreviations
• Use generic names rather then brand name
• Use standard equipment—one kind of pump or syringe
• Use protocol for complex medication administration e.g. heparin, chemotherapy
Prescriber Action to Reduce MEPrescriber Action to Reduce ME
• Stay current & knowledgeable concerning changes in medication & treatment
• Utilize pharmacist consultation if available
• Ensure that drug orders are complete, clear, unambiguous & legible
Including patient weight, dosage (mg/kg/dose or/day), frequency & route of administration
Avoid use of terminal zero e.g. use 5 rather 5.0
Use a zero to the left of a zero ( use 0.2 rather .2 )
• Discuss medication changes with nursing & other staff & families
Pharmacy Action to Reduce MEPharmacy Action to Reduce ME
• Independent double check orders both on calculation & preparation
• Clarify confusing orders
• Checking for current patient drug allergy
• Dispense medication using unit-dose, ready to administration form whenever possible
• Patient name, generic drug name, patient specific dose on all labels
Nursing Action to Reduce MENursing Action to Reduce ME
• Double check medication calculations
• Verify drug order & confirm patient identity & weight before administration
• Have access to drug information on all medications
• Familiar with the operation of medication administration device
Medication Error Reporting Systems
Medication Error Reporting Systems
Medication Error Reporting SystemMedication Error Reporting System
• International systems
• National system
• Local (in hospital or healthcare setting) system
• No system
International SystemsInternational Systems
• The Medication Error Reporting Program operated by United States Pharmacopoeia in cooperation with the ISMP
• The Joint Commission on Accreditation of Healthcare Organization (JCAHO) sentinel event reporting system
• The FDA MedWatch program
• MEDMARX®
• The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
PharmacovigilancePharmacovigilance
• Data gathering related to the detection, assessment, understanding, and prevention of adverse events
• Identifying new information about hazards associated with medicines, preventing harm to patients
• Medical errors are broader category which includes adverse reactions but also other factors (diagnostic errors, equipment failure, nosocomial infections ... )
The Role of Pharmacists in Medication Error PreventionThe Role of Pharmacists in
Medication Error Prevention
How Can Pharmacists Reduce ME?How Can Pharmacists Reduce ME?
• Clinical pharmacist
• Drug & poison information pharmacist
• Staff pharmacist
• Medication safety pharmacist??
Pharmacist on Patient-Care TeamPharmacist on Patient-Care Team
• A full-time unit-based clinical pharmacist substantially decreased the rate of serious medication errors in ICU by 66%
• Studies shows that clinical pharmacy services & increase hospital pharmacy staffing are associated significantly with reduction in medication errors
Leape LL et al. JAMA.1999, Kaushal R et al. American Journal of Health-System Pharmacy.2008
Clinical Pharmacy & ME Reduction Clinical Pharmacy & ME Reduction
• Drug histories
• Drug information services
• Adverse drug reaction monitoring
• Drug protocol management
• Medical rounds participation
Bond CA et a. Pharmacotherapy.2002
51%
18%
13%
38%
29%
Always remember
“to Err is Human!”
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