MEDICATION ERRORS

Medication errors definition

The American society of health systems pharmacists (ASHP) defined medication errors includes,

Prescribing Administration

Dispensing Medications patient Compliance errors

 What is the medication error? is an event connected with the use of medication That event should be prevented through effective control systems {A consumers has 0 error expectation}

Where do errors occur? 1. 2. 3. 4. 5. Prescribing Transcribing (writing down) Dispensing Administering patient non compliance errors

1.

Medication Prescribing Process Components: Communication

Written Prescription Orders Medication Ordering Systems

Electronic Order Transmission

Dosage Calculations Verbal Orders

Written Medication Orders: illegible (Unreadable) Handwriting

Represents common cause of prescribing errors
Delays medication administration Interrupts workflow Prevalent and expensive claim in malpractice cases

 Written Medication Orders: illegible (Unreadable) Handwriting (continued) The written medication order is the first place in which a prescribing error may occur
Due to poor handwriting, written orders require extra time to interpret Worse, illegible handwriting on medication orders is a common cause of prescribing errors, and patient injury and death have resulted

Written Medication Orders: illegible (Unreadable) Handwriting (continued

There may be legal result to illegible handwriting. In order to clarify these illegible orders the health care practitioners work flow is typically interrupted.

In order to prevent prescribing errors, written medication orders should

be readable; include complete information; consider patient-specific information; avoid abbreviations; express weight, volumes, and units using the metric system; avoid decimals; deal cautiously with drug names; and include the medication's purpose.

Written Medication Orders: physicians have to avoid decimals

Use 500 mg for 0.5 g Use 125 mcg for 0.125 mg Never leave a decimal point naked Haldol .5 mg Haldol 0.5 mg Never use a terminal zero Colchicine 1 mg not 1.0 mg Space between name and dose Inderal40 mg Inderal 40 mg Pharmacist should equally be careful when dealing with decimals calculation

A line on colchicines made the dose look more like 10 mg

The Synthroid order looks more like 1 mg than 0.1 mg.

Lined prescription forms

After receiving an overdose for several weeks, the patient was admitted to the hospital for hyperthyroidism and wt loss. The medication error was recognized during a medical history when the patient showed a physician the prescription container label. At the time, tablets of 0.5 mg were marketed so the error was made using only two tablets per dose.

Synthroid =LEVOTHYROXINE, is a thyroid hormone

Written Medication Orders: Drug Names that look- or sound-alike

They increase the risk for medication errors When they have overlapping dosage ranges the potential for errors may be even greater

Written Medication Orders:Drug Names that look- or sound-alike

Confirmation bias is a common cause of name mix-ups . For example, a health care provider in a poorly written medication order may see the name of a drug with which he/she is most familiar and overlook any evidence to the contrary

Written Medication Orders: Drug Names

Some pharmacy computer systems have software to alert pharmacists about problem name pairs and some of the pharmacy benefit managers are beginning to alert pharmacists during the prescription adjudication process For example, a note reminds the pharmacist entering an order for Norvasc(a mlodipine) treats high blood pressure and the chest pain of angina) that it often looks like Navane.(THIOTHIXENE ) is used to treat schizophrenia)

The pharmacist can then confirm the order if necessary.

Written Medication Orders: Drug Names

Another potential medication prescribing error, related to drug name, may occur when a suffix is added to an already marketed drug name. Sometimes suffixes are erroneously left off of prescription orders.
For example, if a prescription for Depakote ER is accidentally written as Depakote, the patient would receive the wrong dosage form.
Depakote ER ,epilepsy migrane

Look-alike & Sound-alike Drug Names

This list No1 of look-alike and/or sound-alike drug name pairs have been reported to the USP Medication Error Reporting Program. May not sound alike when they are read or look alike in print; however, when handwritten or communicated verbally they can be confused A more complete list of these drug name pairs can be obtained at www.usp.org/reporting/review/qr66.pdf.

List No1:Look-alike and or Sound-alike Drug Names

Accupril Alprazolam Accutane Lorazepam

Cardene
Flomax Lamisil Nizoral Plendil Zantac

Cardura
Fosamax Lomotil Neoral Prilosec Zyrtec

USP Quality Review. www.usp.org/reporting/review/qr66.pdf accessed on February 6, 2001.

are two examples of look-alike drug names Examples above

1. Flouroquinolone( antibiotic) Tequin (gatefloxacin) or Tegretol (carbamazepine), a drug used in epilepsy? 2. The anticoagulant Coumadin (warfarin) or Avandia (rosiglitazone), for treating diabetes Imagine the harm to a patient who received the wrong medication in either of these cases

remind prescribers to include the purpose of the medication

Some prescription forms remind prescribers to include the purpose of the medication.
this allows the pharmacist an additional method to check their interpretation of the order Since few look-alike and sound-alike drug pairs have similar therapeutic indications, these types of errors may be avoided by stating the purpose for which the medication is prescribed

Resistance to including the purpose of the medication on a prescription

sometimes arises from: the fear of violating patient confidentiality, the extra time required, and the concern that insurers will deny payment for off-label indications.

remind prescribers to include the purpose of the medication

Some physicians use prescription pads with icons to describe each medications purpose Use of the icons may overcome some of the concerns associated with including the medication's purpose on a prescription. A vertical bar displays icons which represent various therapeutic categories.

remind prescribers to include the purpose of the medication

This vertical bar(next slide). The prescriber then places a check in front of the appropriate icon e.g. circle the blood pressure cuff for antihypertensives, the heart for cardiac medications, etc. There are over 30 icons available to satisfy the needs of different specialties

Insert Figure 3

ohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Medication Prescribing Process: Electronic Prescribing

Computer with 3 Interacting Databases Drug History Drug Information/Guidelines Database Patient-Specific Information i.e., age, weight, allergies, diagnoses, and laboratory data Avoids Illegible Prescriptions Improper Terminology Ambiguous Orders Incomplete Information
Schiff GD. JAMA 1998; 279: 1024-9.

Medication Prescribing Process: Electronic Prescribing

electronic prescribing tools could minimize medication errors related to handwriting. such devices are not widely used could eliminate illegible prescriptions could ensure the use of proper terminology Could ensure that complete information could be avoided

Medication Prescribing Process: Electronic Prescribing

Computers can maintain accurate, unbiased, and up-todate drug databases. Prescribers can receive on-screen prompts for drugspecific dosage information, with reminders to ensure that look-alikes and sound-alikes are not confused. Vital patient-specific information, such as overdose warnings, drug interactions, and allergy alerts, can be presented in the course of prescribing, so that potential adverse drug events that would otherwise go unrecognized can easily be avoided.

Medication Prescribing Process: Electronic Prescribing

EP can expedite refill requests, once patients are entered into the system. Computers can facilitate data exchange to enhance teamwork between clinicians and professionals who represent other parts of the medication management system, such as;
pharmacists in retail, hospital, and online environments; pharmacy benefit managers (PBMs); and health plans.

Medication Prescribing Process: Electronic Prescribing

Computers updates physicians on changes in formularies and insurance coverage.
Computers use can reduce healthcare costs through time and efficiency savings and by encouraging prescribers to consider lowercost drug options.

Medication Prescribing Process: Electronic Prescribing

Easy-to-use point-of-care systems, some that offer comprehensive applications in real time, are becoming available from a number of manufacturers-and at perhaps a surprisingly low cost of entry.

Medication Prescribing Process: Electronic Prescribing

Such integrated programs may provide:
benefits for cost and risk management as well as for clinical care, and they may enhance the prescribing process beyond addressing penmanship alone.

Medication Prescribing Process: Electronic Prescribing

For example, hand-held devices can alert practitioners to potential drug or allergy interactions via up-to-date databases of medications that are connected with patient records. That kind of functionality should help to expand rapidly adoption of electronic prescribing among practitioners.

Medication Prescribing Process: Electronic Prescribing

Of course, computerized medication management systems certainly are not the only solution. Moreover, clinicians' use of hand-held technology will not solve the broad spectrum of medication errors, for technology is but one part of a larger solution that includes such simple and low-tech strategies as separating look-alike medications in a dispensing cabinet. Still, while technology does not offer a perfect solution,

 ISMP( inistitute of save medication practice) does believe that technology, if ppropriately and aggressively used, holds great promise for : researching, identifying, reporting, and reducing medication errors.

 In particular, ISMP believes that:

electronic prescribing with proper systems design, implementation, and maintenance can contribute significantly to the prevention of medication errors today.

 In particular, ISMP believes that:

There is no reason to wait for legislative activity or task forces to insist that this capability be utilized as fully as possible. Put simply, handwritten prescriptions ought to be a thing of the past.

Dosage Calculations
Recognized cause of medication errors Use patient-specific information
height weight age body system function

should be used to calculate dosages when the medication is influenced by those factors.1

ohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Verbal Orders: Error Prevention

Avoided when possible Pronounce slowly and distinctly State numbers like pilots
(i.e., one-five mg for 15 mg)

Spell out difficult drug names Specify concentrations

hen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Verbal Orders: Error Prevention

V.orders should be avoided whenever possible When a verbal order is necessary, it should be spelled out slowly and distinctly Numbers should be stated in the way pilots state them ( i.e., one-five mg instead of fifteen mg) Difficult drug names should be spelled out. For example, an order for NPH insulin 16 units can easily sound like NPH insulin 60 units.

Verbal Orders: Error Prevention

Read back is an important way to prevent errors due to misinterpretation of verbal orders. In the example above, had the listener repeated the dose as six-zero units the error would have been readily recognized. Physicians who telephone prescriptions should ask the pharmacist (or nurse) to repeat the medication order, spelling the drug name that was heard. Was that Cerebyx for epileptic seizures. or Celebrex(NSAID)?

Verbal Orders: Error Prevention

various strengths and concentrations of specific liquid medications are available, concentrations or strengths should be specified for orders Avoid giving the dose in number of teaspoonful, tablets, ampoules or vials.

Verbal Orders: Error Prevention

E.g. Tylenol infant drops (available as 80 mg acetaminophen/ 0.8 mL); were confused with childrens acetaminophen elixir (160 mg/5 mL).

Pharmacist and medication errors

Pharmacists are responsible for the accurate dispensing of medications Pharmacists have a long-standing interest in improving medication safety and have studied the ways and means to reduce medication errors. Yet they can make errors

44

Pharmacist and medication errors

Dispensing errors generally fall into 2 broad categories: 1. errors of commission: (ie, dispensing the wrong medication) errors of omission are errors in judgment 2. errors of omission: failure to counsel patients, ignoring a significant drug interaction or allergy history, or improper patient specific dosing Errors of commission usually are mechanical in nature

Pharmacist and medication errors Dispensing errors

Dispensing is an integral part of the quality use of the medicines& together with the patient counseling form the core professional activities of a pharmacist. These activities allow the safe and efficient provision to the general public of what would normally be dangerous or restricted drugs.

Pharmacist and medication errors Dispensing errors

dispensing errors may be extensive, including patient morbidity and mortality, increased health expenditure due to hospitalization and treatment, and loss of credibility and professional standing for the pharmacist along with the risk of court case and financial loss.

Dispensing errors(continued)
Dispensing errors generally refers to errors in: the dispensing process e.g. 1. wrong drug or dose strength 2. incorrectly labeled directions 3. drug dispensed to wrong patient that are not detected and corrected prior to the patient leaving the pharmacy and which may be to sub optional outcome of treatment for the patients. 4. incorrect admixtures of medications within the pharmacy

Main risk factors associated with the Dispensing errors

prescription overload lighting levels Noise interruptions and distractions Also the major parts of the dispensing errors were related to wrong drug or wrong strength

Most Common Causes of Errors Cited By Pharmacists

Too many telephone calls Overload/unusually busy day Too many customers Lack of concentration No one available to double-check Staff shortage Similar drug names No time to counsel Illegible prescription Misinterpreted prescription

Dispensing error
Administration Errors: An error originating during the process directly associated with medication administration at the nursing unit Monitoring errors: Failure to review a prescribed regimen for appropriateness, or failure to use appropriate clinical or laboratory data for adequate assessment of resident response to prescribed therapy. Potential errors: A mistake in prescribing, dispensing or planned medication administration that is detected and corrected through intervention before actual medication administration. Compliance errors: Inappropriate resident behavior regarding adherence to a prescribed medication administration.

Pharmacy Actions to Decrease Medication Errors

Pharmacists are to be available to prescribers and nurses and committed to participate in drug therapy development and monitoring No guessing or assumption for a confusing medication order Review an original copy of the written medication order before dispensing a medication, except in emergency situations. Prepare drugs in a clean and orderly work area with a minimum of interruption Dispense medication in a timely fashion using a unit-dose, ready-to-administer form whenever possible. Provide counsel to patients or caregivers about their drugs

Actions to Decrease Medication Errors

Actions to Decrease Medication Errors are available in literature for nurses physicians, prescribers and patients and also further details

Pharmacy Actions to Decrease Medication Errors, further details

Lock up/remove drugs that may cause catastrophic medication errors Develop and implement careful procedures for drug storage
Use reminders, such as labels and computer notes, to prevent mistakes with "look-alike" and "sound-alike" drug names Keep the original prescription order, the label, and the medication container together throughout the dispensing process

Perform a final check on the contents of prescription containers

Compare the contents of the medication container with information on the prescription label

Role Of Pharmacists In Medication Errors Reduction

Medication errors can occur at any time The reports of medication errors and interventions should be evaluated and incorporated in to Continuous Quality Improvement program (CQI) The pharmacist must assume responsibility for developing and implementing a plan for the prevention of medication errors through detection and evaluation

Pharmacist and Assessment

Pharmacist needs to: Examine and evaluate the cause of medication errors and analysis of aggregated data to determine trends, significances, frequency and outcomes Evaluate the medication use process in collaboration with other healthcare professionals Establish a process for identifying and tracking medication errors categories of medication errors, e.g. prescribing, dispensing, administration, monitoring, compliance errors, etc. develop a medication error reporting and evaluate form (a simplified documentation system)

Pharmacist and prevention

Increase awareness of medication error through educating about the importance of all medication errors Establish systems for detecting medication error in the facility and pharmacy, e.g. observation, random sampling, and medication storage survey etc. Involve healthcare practitioners, patients and care givers in the medication error detection and reporting process

Pharmacist and Reporting

Donot focus on the punitive aspects to encourage medication error reporting and focus on the improvement of process and systems.

Respect the confidentiality of patient, facility and personnel involved in the medication errors

Pharmacist and Reporting

Pharmacists should lead efforts to examine where errors arise in the drug use system. A quality assurance program that regularly examines all aspects of the drug use system and also produce information required to identify problems and allow for appropriate changes is necessary

Partners collaboration
Pharmacists, pharmacy technicians, and other health care professionals involved in the medication use process must work together to develop a systems approach to medication error reduction

Remember once more

The interruptions to the pharmacist should be reduced as they break up the attention on the prescription at hand. Distraction by non professional activities was potentially dangerous and this should not occur. Interruptions can be reduced by providing a comfortable waiting area and providing pharmacist support personnels (Technician or Assistant).

Remember once more

The difficulty that community pharmacies had in separating commercial and patient care interest may also be cited as a major reasons for incomplete professionalism. The overall medium response to reduce the Medication errors like, having mechanism for checking dispensing procedures, systematic dispensing workflow, checking original prescriptions, keeping knowledge of the drugs up to date etc.

The importance of quality assurance procedures

It reduces the occurrence

if well designed it will lead to identifying the errors and implement strategy to correct them

Standards in the dispensing process must set appropriately high towarss a zero error

Detection of Medication Error

To make safer systems we must be able to learn from previous errors and detection is the first key step We are made vigilant and our knowledge of risks is raised and our performance may be improved by visiting the: reports, alerts and recommendations made available on the web, issued by national and federal healthcare systems, regulatory agencies, and non-profit-making organizations [ (FDA, EMEA), (USP-MEDMARX), (UK NHS) etc

Detection of Medication Error

The approaches used to detect errors are likely to be different in research and routine care, given the available resources to prevent medication errors and reduce the risks of harm, detection tools are needed systems must be able to analyze errors and identify opportunities for quality improvement and system changes

The major methods for detecting adverse events are 1. chart review 2. computerized monitoring 3. incident reporting and 4. searching claims data

for medication errorsDetection methods to be discussed 1. Chart review

2. Claims data 3. Incident reporting (sentinel events) Voluntary reporting Administrative data examination 4. Computer monitoring Direct care observation Patient monitoring