Medication Errors Prepared by: Abdullhadi Burzangy

Introduction In USA, Institute of Medicine report on medication errors (2000): Medical errors: 8th leading cause of death, resulting in 44,000 - 98,000 deaths annually. In contrast, Highway accidents: 43,458 Breast cancer: 42,297,AIDS: 16,516. Medication errors account for an estimated 7,000 deaths & injure approximately 1.3 million people per year nationally.

Definition of “medication error” "A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and; compounding; dispensing; distribution; administration and use."

Cost of medication errors Patients injured as a result of a medication error stay in a hospital longer and have higher hospital costs. It costs $17-$29 billion annually.

Cost of medication errors At the hospital in Utah, adverse drug events caused complications in 2.4% of admissions, cost an average of $2,262 per patient, and lengthened the stay by 1.9 days compared with matched controls.

Medication Errors Medication errors can occur anywhere in these areas: Prescribing. Repackaging. Dispensing. Administering. Storage.

The intensity of care also affects the risk of injury The intensity of care also affects the risk of injury. Among pediatric patients admitted to a British university hospital, drug errors were 7 times more likely to occur in the intensive care unit than elsewhere

Types of errors Wrong drug. Wrong dose. Missed dose. Wrong dosing frequency. Wrong dosage form. Wrong time. Wrong route. Wrong I.V. rate Wrong I.V. solution.

Types of errors Wrong patient. Failure to account for patient characteristics in making drug therapy decision. Inappropriate indication for use. Calculations ,decimal points, unit of measure. Known allergy. Expired date . Drug interaction.

Common causes of such errors include: Poor communication. Ambiguities in product names, directions for use, medical abbreviations or writing. Patient misuse because of poor understanding of the directions for use of the product . Work load (30 prescription order/hour).

Causes of medication error Doctors orders change frequently. Names of medicines are similar. Pharmacy delivers incorrect dose. Doctor notes is not clear.

Causes of medication error Patients on similar medicines. No communication when next dose due. Look alike medicines. Look alike packaging.

Prescription writing The following important points should be noted: Prescription must be printed in English without abbreviations. Name of the drug should be written clearly &not abbreviated. Dose & dose interval must be stated. Computer issued : The dose will be in numbers ,frequency in words &quantity in number in practice. e.g. Amoxycillin cap. 500mg one cap. three times daily (21). 2. Hand-written: Quantities to be supplied may be stated by indicating the number of days required for a treatment e.g. Rx Paracetamol tab. 500mg 2×3×7.

for liquid , we use milliliter (ml) not cc or Cm3. Quantities in Rx Microgram & nanogram should not be abbreviated. The unnecessary use of decimal points should be avoided: If the decimal point cannot be avoided as for value less than 1, write zero before the value. E.g. 0.5ml not .5 ml. for liquid , we use milliliter (ml) not cc or Cm3. Quantities in Rx Correct method Wrong way 1- 1 gram or more. 2 g 2.0 g 2- less than1gram& more than 1 milligram. 100 mg 0.1g 3- less than 1 milligram, written in microgram 100 microgram 0.1mg or 100 μg

Table 1. Commonly Misinterpreted Medical Abbreviations Possible Misinterpretation Intended Meaning Abbreviation Mistaken as a zero or a four (4) resulting in overdose. Units U Mistaken for "mg" resulting in a 1,000-fold overdose. Micrograms µg The period after the "Q" has sometimes been mistaken for an "I," and the drug has been given QID rather than daily. Every day QD Misinterpreted as "QD" or "QID." If the "O" is poorly written, it looks like a period or an "I." Every other day QOD Mistaken as "SL" (sublingual) when poorly written. Subcutaneous SC or SQ Misinterpreted as "three times a day" or "twice a week." Three times a week TIW Patients' medications have been prematurely discontinued when "D/C" was intended to mean "discharge" versus "discontinue." Discharge; also discontinue D/C Misinterpreted as the abbreviation "HS" (hour of sleep). Half strength HS Mistaken as "U" (units) when poorly written. Cubic centimeters cc Misinterpreted as the abbreviation "OU" (both eyes); "OS" (left eye); "OD" (right eye). Both ears; left ear; right ear AU, AS, AD  

Reporting Human beings make mistakes. Mistakes can be prevented by designing systems “that make it hard for people to do the wrong thing and easy for people to do the right thing.” To design such systems and evaluate their effectiveness, we need to start with baseline information.

Benefits of reporting medication errors: *To decrease the incidence of medication errors. *For Patients safety. * To improve each step in the medication delivery process.

Benefits of reporting medication errors: *To improve clinical practice and quality of care. *To Educate patients regarding strategies to prevent medication errors. *To maximize the safe use of medications.

Benefits of reporting medication errors: *Identify gaps in research that hinder the understanding of medication errors. *Promote research to expand knowledge regarding medication errors, their causes, and the effectiveness of interventions.

Medication-error Reporting Reporting of medication errors is crucial …but traditionally punitive. If reporting is inadequate, we cannot identify problems. Studies conclude that 45-95% of medication errors are not reported.

Why are medication errors not reported? Administration looks at individual not system. Nurses are blamed if something happen to patient due to error. Nurses fair adverse consequences from reporting Nurses believe peers will think them incompetent . Nurses don’t think error is important enough.

Why are medication errors not reported? Patient / family may sue. No positive feedback when medication given correctly. Response from administration dose not match the severity. Report takes too long to complete.

Medication error reporting Increase awareness of reporting system available to or within health care organization . Stimulate & encourage reporting of medication errors both locally &nationally. Develop standardization &classification for the collection of medication errors reports so that data base will reflect reports &grading system. Maintain system to support & provide feedback to reporters so that appropriate prevention strategies can be developed in facilities.

Medication error prevention Encourage standardization of error-prone aspect of prescribing, delivering & administrating. Encourage reliance on system-based solutions to enhance the safety of medication use & to minimize the potential for human error. Explore the potential for computer-based information systems in the prevention of medication error.

Medication error prevention Increase awareness of the need for distinctive packaging, labeling& nomenclature of product associated with actual or potential medication error. Educate consumers and patient regarding strategies to prevent medication error for both prescription and nonprescription medication. Educate health care professional regarding strategies to prevent medication error .

Medication error prevention Presence of a drug information service. Pharmacist-provided drug protocol management. Pharmacist-participation in medical rounds. Increase staffing of clinical pharmacist.

Medication error prevention Pharmacists fill no more than 15 prescriptions / hour. Avoid verbal drug orders. Avoid abbreviations. Use of medication-dispensing machines.

THANK YOU