Medication Safety

Angelina Jolie was ordered Lasix® 1 mg/kg via IV push Angelina Jolie was ordered Lasix® 1 mg/kg via IV push. Brad Pitt, RN, obtained the vial of IV medication, but gave it to Angelina orally.

Administration Error

Matt Damon was prescribed Ciprodex® otic suspension- 4 gtts AS BID Matt Damon was prescribed Ciprodex® otic suspension- 4 gtts AS BID. Ben Affleck, RN, administers the medication in his left eye, twice a day.

Administration Error

Doctor Phil calls CVS to phone in a prescription for Oprah Winfrey, who will be discharged today. He wants the following prescription: Plavix 75 mg #50, 1 po daily The pharmacist transcribes the prescription as follows: Patient Name: Oprah Winfrey Address: 123 Madeup Lane, Deerfield IL 60015 Rx Plavix 75 mg tablets Disp#15 Ṫ cap po every day Signature: Dr Phil

Dispensing Error

Doctor Drew calls CVS to phone in a prescription for patient Susan Pinsky. He wants the following prescription dispensed: Amoxicillin 500 mg, 1 cap po TID x 10 days. The pharmacist dispenses 21 capsules of Amoxicillin to the patient.

Dispensing Error

Doctor Who writes the following prescription for his patient who will be discharged today. Patient Name: David Tennant Address: 123 Madeup Lane, Deerfield IL 60015 Rx Warfarin #XV 1 tab po every other day Signature: Doctor Who, MD

Prescribing Error

What type of workplace issues may contribute to medication errors?

Noise Stress Multi-Tasking Similar medication labels Medication labels that are difficult to read

Name 2 items on the Joint Commission's “Do Not Use” list, and explain why they are on that list.

Do Not Use Item Potential Problem Use Instead U, u (unit) Mistaken for zero, the number 4, or CC Write “unit” IU (international unit) Mistaken for IV (intravenous), or the number “10” ten. Write “international unit” Q.D., QD, q.d., qd (daily) Mistaken for each other Write “daily” Q.O.D., QOD, q.o.d., qod (every other day) Period after the “Q” mistaken for “I” and the “O” mistaken for “I” Write “Every other day” Trailing Zero (X.0 mg) Decimal point is missed Write X Lack of leading zero (.X) Write 0.X mg MS Can mean morphine sulfate or magnesium sulfate Write “morphine sulfate”

To prevent confusion between the following drugs, how should they be written on a prescription? Glyburide & Glipizide

glyBURIDE glipiZIDE

To prevent confusion between the following drugs, how should they be written? Prednisolone & Prednisone

prednisoLONE predniSONE

The ISMP has established a list of medications that should never be crushed before administration. Everybody, give one reason why a medication may be on that list.

Slow-release dosage form Extended release dosage form Enteric coated dosage form May irritate the mucous membrane Rate of absorption may be increased Coating of tablet may release the drug over a period of time Taste Skin irritant Liquid Filled Sublingual dosage form Film-coated dosage form Effervescent tablet Teratogenic effect Local anesthesia of the oral mucosa

A pharmacy technician may ask patients if they have any questions about their medications, but it is the pharmacist’s responsibility to counsel a patient. Let’s Role Play! Can you answer the following questions, or do you have to refer them to the pharmacist?

What medication did my doctor prescribe?

Do I need to take this medication with food?

My birthday is tonight and I would like to have a glass of wine with my dinner. Is it safe with this medication?

Am I supposed to swallow this medication or inject it?

Can you please tell me how to take this medication?

How do I know when I can stop taking this medication?

My husband and I are trying to get pregnant My husband and I are trying to get pregnant. Is this medication safe to take if we succeed?

Items that can be discussed with a Pharmacy Technician: Name of medication Dosage form Dosage Route of administration Items that must be discussed with a Pharmacist: Duration of therapy Action to be taken if a dose is missed Common or severe side effects Interactions and contraindications of the medication (to include food) Self-monitoring of medication Proper storage of medication Special directions for use Questions: My doctor prescribed me something, but didn’t tell me what it is. What is the name of the medication? I have high blood pressure. Is this medication is going to make it better? My sister says I should never store this medication in the bathroom. Is that true? I’m not sure whether my doctor prescribed me the tablets or the syrup. Do you know? My Doctor was supposed to give me 2 mg tablets. Can you tell me what strength was written on the prescription? Will this medication interact with the sudafed I’m taking for my stuffy nose?

Many medications are inappropriate to use in the elderly population due to adverse side effects. Name a few adverse side effects that are especially worrisome in this population, and explain why they’re worrisome.

Anti-cholinergic effects Drowsiness Confusion Constipation Cardiac Problems Carcinogenic Effects Hypoglycemia GI Bleeding Anti-cholinergic effects Questions: My doctor prescribed me something, but didn’t tell me what it is. What is the name of the medication? I have high blood pressure. Is this medication is going to make it better? My sister says I should never store this medication in the bathroom. Is that true? I’m not sure whether my doctor prescribed me the tablets or the syrup. Do you know? My Doctor was supposed to give me 2 mg tablets. Can you tell me what strength was written on the prescription? Will this medication interact with the sudafed I’m taking for my stuffy nose?

What is the FDA MedWatch?

A voluntary program that allows the voluntary reporting of adverse health events and medical problems.

What is FAERS?

FDA Adverse Event Reporting System

A database that contains information on adverse event and medication error reports submitted to the FDA.

What is the benefit of electronic prescribing?

Eliminates illegible prescriptions Uses clinical decision support to reduce preventable errors Improves communication between the clinician and patient Enhances communication throughout the prescribing chain Increases access to patient and reference information Improves work efficacy

What are the advantages of pharmacy automation?

Reduction in medication errors Increased speed in medication processing Manage and track inventory