Systems Analysis, Causes of Medication Errors, and Error-Prone Abbreviations

Learning Objectives Describe the systems factors that play a major role in medication errors Discuss the proximal causes of medication errors Identify error-prone abbreviations and ways to improve communication of ambiguous medication orders

Systems, Not People Medication errors are property of the system as a whole rather than results of the acts or omissions by the people in the system Performance improvement requires changing the system, not changing the people –Practitioners are sometimes held to an unattainable standard—perfection

Perspective Accepting a goal of a 99.9% success rate, we’d have: –2 million documents lost every year by the IRS –A major plane crash every 3 days –16,000 items lost every hour in the mail –37,000 errors every hour by automated teller machines –107 erroneous medical procedures performed every day

Proximal Causes of Medication Errors Lack of drug knowledge Lack of patient information Rule violations Slips and memory lapses Transcription errors Faulty drug identity checking Faulty interaction with other services Faulty dose checking Infusion pump and parenteral delivery problems Inadequate patient monitoring Drug stocking and delivery problems Preparation errors Lack of standardization Leape LL. JAMA 1995;274:35–43.

Distribution of Medication Errors by Proximal Cause Leape LL. JAMA 1995;274:35–43.

1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10. Quality processes and risk management 10 Key Elements of the Medication System

Causes of Errors Based on Key System Elements Lack of information about the patient Lack of information about the drug Communication and teamwork failure Unclear, absent, or look-alike drug labels and packages, and confusing or look-alike or sound-alike drug names Unsafe drug standardization, storage, and distribution

Causes of Errors Based on Key System Elements (continued) Nonstandard, flawed, or unsafe medication delivery devices Environmental factors and staffing patterns that do not support safety Inadequate staff orientation, ongoing education, supervision, and competency validation

Causes of Errors Based on Key System Elements (continued) Inadequate patient education about medications and medication errors Lack of a supportive culture of safety, failure to learn from mistakes, and failed or absent error-reduction strategies, such as redundancies

1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10. Quality processes and risk management 10 Key Elements of the Medication System

Patient Information 18% of serious preventable adverse drug events (ADEs) attributable to insufficient information before prescribing, dispensing, and administering 29% of prescribing errors alone attributable to a lack of patient information

Patient Information Lack of critical patient information –Current laboratory values –Height, weight –Diagnoses –Pregnancy, breastfeeding –Allergies –Other drug therapies Lack of interface between laboratory and pharmacy systems Medication reconciliation

Patient Information Ideally, essential information is obtained, readily available in useful form, and considered when prescribing, dispensing, and administering medications

1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10. Quality processes and risk management 10 Key Elements of the Medication System

Drug Information 35% of preventable ADEs attributable to inadequate dissemination of drug information One in six ADEs caused by a combination of: –Insufficient knowledge of drug doses –Miscalculations –Incorrect expression of measurement or drug concentration

Drug Information Lack of accessible or up-to-date references Lack of a tightly controlled formulary Failure to use standardized drug protocols Computer systems that fail to detect unsafe orders Lack of clinical pharmacists in patient care areas Handwritten medication administration records

Drug Information Ideally, essential drug information is readily available in useful form to those ordering, dispensing, and administering medications

1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10. Quality processes and risk management 10 Key Elements of the Medication System

Communication of Drug Information Barriers that lead to ineffective communication dynamics Unclear order communication –Ambiguous or incomplete orders Illegible handwriting Look-alike and sound-alike drug names Verbal orders misspoken or misheard

More Types of Failed Communication Zeroes and decimal points –Always use a “leading zero” (a zero before the decimal point) –Never use a “trailing zero” (a whole number followed by a decimal point and a zero) Use of apothecary system instead of metric system Poor design of computer-generated medication administration records Dangerous abbreviations and dose designations

Misinterpreted Physician’s Prescriptions Study showed that medication errors consequential to misinterpreted physician’s prescriptions were the second most prevalent and expensive claims listed on 90,000 malpractice claims filed over a 7-year period

Avoid Dangerous Abbreviations Letter “U” for unit “QD” or “qd” for daily “QOD” or “q.o.d.” for every other day IU (International Unit) may be mistaken for IV (intravenous)

Look-Alike and Sound-Alike Drug Names LamisilLamictal TaxolTaxotere VincristineVinblastine AmrinoneAmiodarone RitonavirRetrovir

Communication Ideally, methods of communicating drug orders and other drug information are standardized and automated to minimize the risk of error

10 Key Elements of the Medication System 1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10. Quality processes and risk management

Look-Alike Packaging Sound-Alike Drug Names

Drug Labels and Packaging Ideally, strategies are undertaken to minimize the possibility of errors with products that have similar or confusing labels, packages, or drug names

10 Key Elements of the Medication System 1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10. Quality processes and risk management

Drug Distribution Practices Unit-dose system Floor stock Computer-generated labels Automated dispensing equipment Drug storage Pharmacy access after hours

Drug Standardization, Storage, and Distribution Ideally, intravenous solutions, drug concentrations, and administration times are standardized whenever possible Unit-based floor stock is restricted

Drug Standardization, Storage, and Distribution Medications should be provided to patient care units in a safe and secure manner and available for administration within a time frame that meets essential patient needs

10 Key Elements of the Medication System 1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10. Quality processes and risk management

Problems Related to Drugs and Drug Devices Labeling and packaging Automated compounders Infusion pumps

Medication Delivery Devices Ideally, the potential for human error is mitigated through careful procurement, maintenance, use, and standardization of devices used to prepare and deliver medications

10 Key Elements of the Medication System 1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10.Quality processes and risk management

Problems With Environmental Factors and Staffing Patterns Lack of space, crowded and disorganized storage Poor lighting, excessive noise High patient acuity Deficient staffing, excessive workloads

Environmental Factors and Staffing Patterns Ideally, medications are prescribed, transcribed, prepared, and administered in a physical environment that offers adequate space and lighting and allows practitioners to remain focused on medication use

Environmental Factors and Staffing Patterns The complement of qualified, well-rested practitioners matches the clinical workload without compromising patient safety

10 Key Elements of the Medication System 1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10.Quality processes and risk management

Staff Competency and Education Ideally, practitioners receive sufficient orientation to medication use and undergo baseline and annual competency evaluation of knowledge and skills related to safe medication practices

Staff Competency and Education Practitioners involved in medication use are provided with ongoing education about medication error prevention and the safe use of drugs that have the greatest potential to cause harm if misused

10 Key Elements of the Medication System 1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10.Quality processes and risk management

Patient Education Problems –Failure to adequately educate patients –Lack of pharmacist involvement in direct patient education –Failure to provide patients with understandable written instructions –Lack of involving patients in check systems –Not listening to patients when they express a concern or question their therapy

Patient Education Inform patient of drug names, purpose, dose, side effects, and management methods Suggest readings for patient Inform patient about right to ask questions and expect answers Listen to what patient is saying and provide follow-up!

Patient Education Ideally, patients are included as active partners in their care through education about their medications and ways to avert errors

10 Key Elements of the Medication System 1.Patient information 2.Drug information 3.Communication related to medications 4.Drug labeling, packaging, and nomenclature 5.Drug standardization, storage, and distribution 6.Medication delivery device acquisition, use, and monitoring 7.Environmental factors and staffing patterns 8.Staff competency and education 9.Patient education 10.Quality processes and risk management

Culture Change Provide leadership Design job to: –Avoid reliance on memory –Promote simplification and standardization Promote effective team functioning Anticipate the unexpected –Design for recovery Create a learning environment

Quality Processes A nonpunitive, system-based approach to error reduction is in place and supported by management, senior administration, and the board of trustees

Accountability in Systems A nonpunitive, system-based approach to error reduction does not diminish accountability; rather, it redefines accountability and directs it in a productive and useful manner

Quality Processes Ideally, practitioners are stimulated to detect and report errors, and interdisciplinary teams regularly analyze errors that have occurred within the organization and in other organizations for the purpose of redesigning systems to best support safe practitioner performance

More on the Problem of Error-Prone Abbreviations, Symbols, and Dose Designations

Problems With Medical Notation Ambiguous medical notations are one of the most common and preventable causes of medication errors Drug names, dosage units, and directions for use should be written clearly to minimize confusion

Consequences of Using Error-Prone Abbreviations Misinterpretation may lead to mistakes that result in patient harm Start of therapy may be delayed because of time spent for clarification

Implement “Do Not Use” List The Institute for Safe Medication Practices (ISMP) and the Food and Drug Administration recommend that ISMP’s list of error-prone abbreviations be considered whenever medical information is communicated To access the complete list, go to:

Consider All Forms of Communication Written orders Internal communications Telephone/verbal prescriptions Computer-generated labels Labels for drug storage bins Medication administration records Preprinted protocols/prescriptions Pharmacy and prescriber computer order entry screens

Short List of Error-Prone Notations The following notations comprise The Joint Commission “Do Not Use” list and should never be used: Notation ReasonInstead Use U Mistaken for 0, 4, cc“unit” IU Mistaken for IV or 10“unit” QD Mistaken for QID “daily”

Short List of Error-Prone Notations Notation Reason Instead Use QOD Mistaken for QID, QD “every other day” Trailing zero Decimal point missed “X mg” (X.0 mg) Naked decimal Decimal point missed “0.X mg” point (.X mg)

Short List of Error-Prone Notations Notation Reason Instead Use MS Can mean morphine “morphine sulfate” sulfate or magnesium sulfate MSO 4 and Can be confused “morphine sulfate” MgSO 4 with each other or “magnesium sulfate” cc Mistaken for U “mL”

Short List of Error-Prone Notations Notation Reason Instead Use Drug name Mistaken for other Complete abbreviations drugs or notations drug name (especially those ending in “l”) > or < Mistaken as “greater than” opposite of intended or “less than” μg Mistaken for mg“mcg”

@ Mistaken for 2 “at” & Mistaken for 2 “and” / Mistaken for 1 “per” rather than a slash mark + Mistaken for 4 “and” Short List of Error-Prone Notations NotationReason Instead Use

AD, AS, AUMistaken for OD, OS, OU“right ear,” “left ear,” or “each ear” OD, OS, OUMistaken for AD, AS, AU“right eye,” “left eye,” or “each eye” D/C, dc, d/cMisinterpreted as “discharge” or “discontinued” when “discontinue” followed by list of medications Short List of Error-Prone Notations

Other Good Practices to Avoid Misinterpretation Drug name abbreviations can easily be confused –Always write out complete drug name Apothecary units are unfamiliar to many practitioners –Always use metric units

Example of Misinterpreted Abbreviation Intended dose of 4 units in patient history Interpreted as 44 units “U” should be written out as “unit”

Example of Misinterpreted Abbreviation Intended dose of “.4 mg” Interpreted as 4 mg from medication order Should be written as “0.4 mg”

Example of Misinterpreted Abbreviation Intended “Potassium chloride QD” in medication order Interpreted as QID Should be written as “daily”

Example of Misinterpreted Abbreviation Intended recommendation of “less than 10” Interpreted as 40 Should be written out as “less than” not “<”

Example of High-Risk Abbreviation Use “QD” in advertisement Should be written out as “daily”

Example of Error-Prone Abbreviation in Medical Literature “U” in prominent professional journal article Should be written out as “unit”

Avoid Error-Prone Abbreviations Even in Printed Materials Expressions may still be confused Perpetuates the impression that abbreviations are acceptable Error-prone abbreviations may be copied into written orders

Recommendations for Health Care Professionals Avoid ambiguous abbreviations in written orders, computer-generated labels, medication administration records, storage bins/shelf labels, and preprinted protocols Work with computer software vendors to make changes in electronic order entry programs Provide examples when educating staff on how using error-prone abbreviations have led to serious patient harm Provide staff with ISMP’s list of error-prone abbreviations Introduce health care students to the list of error-prone abbreviations