35 Medication Errors

State Standard 17) Identify strategies for preventing medication errors by distinguishing medications that either look alike or sound alike, such as Ceftin, Cefotan, Cefzil, Rocephin and Cipro. Include strategies related to recognizing high-alert/high-risk medications such as Sporanox for patients who have ventricular dysfunction.

Objectives Student will be able to… Define what a medication Error is. Explore the primary reason for medication errors Identify common types of medication Errors.

Medication Errors Defined as: "Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer."

Medication Errors Defined as: "Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

Medication Errors Four primary reasons for errors defined in 1848 and still exist today Poor handwriting of prescribing physicians Improper and mistaken use of medical and pharmaceutical abbreviations and selection of wrong drugs with various synonyms

Medication Errors Four primary reasons for errors defined in 1848 and still exist today Poor conditions of the environment making it easy to lose concentration while dispensing and selecting the medications correctly Poor training of pharmacy staff and lack of follow-through by the pharmacist in the dispensing process

Medication Errors Five rights of medication administration Right patient Right drug Right route Right dose Right time

Types of Errors American Hospital Association lists some common types of medication errors. Incomplete patient information Unavailable drug information Miscommunication of drug orders

Types of Errors American Hospital Association lists some common types of medication errors. Lack of appropriate labeling as a drug is prepared and repackaged into smaller units Environmental factors that can distract health professionals from their medical tasks

Types of Errors Unordered or unauthorized drug error Administration of a dose of medication that was never ordered for that patient. Also called a wrong drug error

Types of Errors Extra dose error Omission error A dose is given in excess of the total number of times ordered by the physician. Omission error No attempt made to administer the dose

Types of Errors Wrong dose error Wrong route error Dose contains wrong number of preformed dosage units or was more than 17% greater or less than the correct dosage. Wrong route error Dose administered by different route than ordered

Types of Errors Wrong time error Wrong dosage form error Dose given 30+ minutes (or 60+ minutes depending on site) before or after scheduled administration time without an acceptable reason Wrong dosage form error Administration of dose form different from what the physician specified or implied

Types of Errors Age-related errors Pediatric patients especially vulnerable to errors, particularly incorrect dosage based on computation errors and wrong dosage intervals Check and recheck for age and weight. OTC products may not contain pediatric dosing indications or guidelines.

Statistics Each year More people die each year from medical errors than motor vehicle accidents, breast cancer, or AIDS.

Statistics Each year Around 98,000 deaths occur from medical errors. 7,000+ (about 7%) from medication errors Average rate for medication errors is 1.8 (nearly 2 Rx/100 dispensed) = 60 million errors/3 billion Rx filled annually in the U.S.

Statistics Top three drug classes for medication errors Central nervous system Opioid analgesics Sedatives/hypnotics/anxiolytics Anticonvulsants

Statistics Top three drug classes for medication errors Cardiovascular Beta-blockers Diuretics Calcium-channel blockers

Statistics Top three drug classes for medication errors Hormones/synthetics/modifiers Insulin Antidiabetic agents Adrenal corticosteroids

Technology and Errors Computer problems or errors Shorthand directions mistyped, then misread Computer doesn't always recognize abbreviations being used. Choosing wrong drug from database Choosing wrong strength from database

Technology and Errors Read carefully As you type, again when label is printed. Compare original Rx to patient record and printed label.

Technology and Errors Triple check process helps avoid errors Read what is typed carefully As you type Again when label is printed Compare original Rx to patient record and printed label. Read label again before pharmacist does final check.

Look-Alike–Sound-Alike Drugs Drugs with similar spelling or similar sounding names can be confusing.

Table 35-1 Examples of Look-Alike–Sound-Alike Drugs

Look-Alike–Sound-Alike Drugs Generic drug manufactures use standard design on label so similar words look alike, causing confusion. FDA created "Tall-Man Lettering" to help flag potential problem medications. Examples EPINEPHrine and ePHEDrine PREDnisone and predNISOLONE

Activity Complete drug cards for the following… Tolterodine (Detrol) Ranitidine (Zantac) Famotidine (Pepcid) In reference to St. 17, pretend that you are an experienced pharmacist, and create a teaching plan for a new pharmacy technician that outlines types of medication errors, common reasons for errors, and at least 20 common look-alike-sound-alike drugs. Your teaching plan should be at least a page in length, and include objectives and an activity.

Preventing Medication Errors

State Standard 16) Outline in a written or digital presentation industry standards surrounding medication safety. Cite information obtained from textbooks, online and print pharmacy journals, and related websites. Include at minimum the following: a. Error prevention strategies for data entry (e.g., prescription or medication order to correct patient) b. Patient package insert and medication guide requirements (e.g., special directions and precautions) c. Issues that require pharmacist intervention (e.g., DUR, ADE, OTC recommendation, therapeutic substitution, misuse, missed dose) d. Common safety strategies (e.g., tall man lettering, separating inventory, leading and trailing zeroes, limited use of error-prone abbreviations)

Objectives Students will be able to.. Identify the pharmacy technicians role in preventing medication errors. Identify roles of the pharmacy in preventing medication errors. Explore real world medication errors and their consequences.

Preventing Medication Errors Role of the pharmacy technician Pharmacy technicians are responsible for many activities involved in filling and dispensing prescription medications. Evolving role means more responsibilities that were once only performed by pharmacist. Pharmacy technicians must ensure that all medication is correct BEFORE the final check by the pharmacist.

Preventing Medication Errors Hospital-wide action to prevent medication errors Adequate staffing Formulary system with therapeutic uses and evaluations for pediatric uses of certain drugs

Preventing Medication Errors Hospital-wide action to prevent medication errors Track medication errors Formal systems Report errors to families Encourage team environment

Preventing Medication Errors Pharmacy actions to prevent medication errors Technology errors Use past errors to suggest improvements to IT department or pharmacy manager.

Preventing Medication Errors Pharmacy actions to prevent medication errors Concentration errors Understand patients can lash out because they don't feel well, especially at peak times. Don't be overcome by stress. During peak hours, take extra care.

Preventing Medication Errors Pharmacy actions to prevent medication errors Ultimate tool is education. Pharmacist, pharmacy technician, and patient all benefit. Continuing education for pharmacy staff should be mandatory.

Preventing Medication Errors Pharmacy actions to prevent medication errors Ultimate tool is education. Training in automated pharmacy technology and certification courses (IV, compounding, etc.) Keep up with news reports, safety advisories, continuing education programs.

Preventing Medication Errors Pharmacy actions to prevent medication errors Recheck calculations against weight-based dosage ranges Reconfirm confusing orders with physician/pharmacist Check for current allergies and drug compatibilities

Preventing Medication Errors Pharmacy actions to prevent medication errors Prepare drugs in a clean environment and avoid interruptions during preparation Obtain the original written order before dispensing

Preventing Medication Errors Pharmacy actions to prevent medication errors If possible, use a unit-dose or ready-to-use medication form Do not store sound-alike or look-alike drugs next to each other

Preventing Medication Errors Pharmacy education and communication Best practices should include: Checking medication calculations with another team member, especially if unusual in dosage or amount Confirming patient identity and pertinent information before dispensing Educating patients or caregivers about medication before dispensing

Preventing Medication Errors Pharmacy education and communication Best practices should include: Implementing tracking system for errors and communicate with all staff involved on a regular basis to review Answering all questions from caregivers and listen attentively to them Double-checking all orders

Preventing Medication Errors Pharmacy education and communication Best practices should include: Always using proper dispensing utensils, such as droppers or medicine cups; do not use inexact utensils, such as household teaspoons, for measurement or dispensing.

Monitoring and Reporting Errors Institute of Medicine (IOM) recommends e-prescribing to avoid errors from illegible handwriting and abbreviations.

Monitoring and Reporting Errors Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) includes e-prescription incentives. Electronic prescribers could earn a 2% incentive payment during the current year.

Case Studies For each case study, consider: What was the cause of the error? What was the impact of the error? What could have been done to prevent the error?

Case Studies Glynase/ritalin mixup Seven-year-old patient in South Carolina suffered permanent brain damage from Glynase 6 mg instead of Ritalin that was prescribed.

Case Studies mcg/mg mixup Pittsburgh pharmacist mistranscribes phone Rx confusing milligrams and micrograms. Patient receives 2,000+ times recommended max dose, becomes totally disabled.

Case Studies Cycrin/Coumadin Mixup Florida pharmacist dispenses Cycrin (female hormone) instead of Coumadin. Patient suffered stroke, heart attack, permanent coma.

Case Studies Tainted IV bags Compounding pharmacy in Birmingham, AL, source of Serratia marcescens outbreak affecting 19 patients in six hospitals

Case Studies Emily Jerry 18-month-old diagnosed with a yolk sac tumor. Cancer cured but patient died from final chemotherapy treatment. Pharmacy technician used 23.4% sodium chloride solution instead of less than 1%. Pharmacist was distracted by personal phone call and approved solution.

Activity Complete drug cards for the following… Diltiazem (Cardizem) Budesonide+ Formoterol (Symbicort) Codeine + Guanifenesin (Robitussin AC syrup) Per St. 16 Complete a presentation over prevention of medication errors. Guidelines are on the next slide.

* PowerPoint presentation Google Slides (present Friday) 2-3 minutes in length 16) Outline in a written or digital presentation industry standards surrounding medication safety. Cite information obtained from textbooks, online and print pharmacy journals, and related websites. Include at minimum the following: a. Error prevention strategies for data entry (e.g., prescription or medication order to correct patient) b. Patient package insert and medication guide requirements (e.g., special directions and precautions) c. Issues that require pharmacist intervention (e.g., DUR, ADE, OTC recommendation, therapeutic substitution, misuse, missed dose) d. Common safety strategies (e.g., tall man lettering, separating inventory, leading and trailing zeroes, limited use of error-prone abbreviations)

Summary Medication error rate is rising. Know where medication errors occur. Make a conscious effort to reduce medication errors. Report errors to appropriate agencies so everyone can learn from them. Reports can be anonymous or with full details.