1. Medication Safety A medication error is a drug error that may or may not reach the patient It is usually preventable It is usually unintentional May or May not cause harm A medication error that causes death is called a sentinel event by the Joint Commission

2. Type of Medication Errors Prescribing Errors Involves wrong dose, illegible sigs, wrong frequencies Incorrectly transcribing verbal orders from MD Dispensing Errors Results from mistakes made during dispensing Physically preparing medications incorrectly (i.e. using 23.4% saline instead 0.9% saline for an IV admixture) Transcribing sig instructions incorrectly i.e. Methothexate 12.5 mg tablet TIW as 12.5 mg TID Error in dosing calculations Administration Errors Involves nursing Incorrect route of administration Giving KCL 40 meq IVP instead of KCL 40 meq IVPB over 60 minutes (FATAL) Giving Vincristine intrathecally instead of intravenously (Fatal) Giving Penicillin G Benzathine IV instead of IM (can be fatal)

3. Causes of Medication Errors Performance problems Procedure(s) not followed Knowledge deficits Pharmacists/Pharmacy Technicians that may be intoxicated by alcohol or drugs Social or Family problems Noise level at work Distractions

4. Medication Error Reduction Strategies Joint Commission “Do not use” list ISMP (Institute for Safe Medication Practices) error prone do not use list www.ismp.org/tools/errorproneabbreviations.pdf ISMP also publishes a list of confused drug names Example concludes Celebrex-Celexa List can be found at www.ismp.org/tools/confuseddrugnames.pdf www.ismp.org/tools/confuseddrugnames.pdf

5. Tall Man Lettering Tall Man lettering is a strategy implemented by healthcare institutions in the US under the advise of the Joint Commission, FDA and ISMP Involves drug names that can be confused with one and other, see ISMP confused name’s list Drugs with similar sounding names or spelling are called LASA drugs- Look Alike Sound Alike drugs Tall man lettering involves the use of mixed case lettering to distinguish between these drugs Examples: buPROPion VS busPIRone glyBURide VS glipiZIDE hydrALAZINE VS hydrOXYzine Tall man strategies involves: labeling of these medications, ADC cabinet display, separating these drugs on pharmacy shelves

6. High Alert Medications Medications that when used in error can result in serious patient harm including death ISMP has collected a list of such drugs CategoryExamples Concentrated electrolytesKCL 2 meq/ml, Calcium chloride 10%, 3% saline, 23.4% saline Narcotic OpiatesMorphine, Hydromorphone AnticoagulantsHeparin, Warfarin NMBSuccinylcholine, Rocuronium HypoglycemicsInsulin, oral drugs (glipizide) Chemotherapy DrugsMethothexate, Doxorubicin

7. High Alert Medication Strategies US hospitals and healthcare institutions have published their own lists that mirrors the ISMP list with some additions. Strategies include: Specialized color code labeling for these medications Segregating the medications in the pharmacy inventory Restricting access to these drugs in the ADC (non overrideable) Specialized alerts in the CPOE and the pharmacy systems Use of standardized preparations of these drugs i.e. Heparin USP 25,000 units/250 ml D5W

8. Do Not Crush List ISMP publishes a do not crush list These drugs should never be crushed Typically patients that can’t swallow or have feeding tubes, NG tubes and PEG tubes have their oral dose forms crushed and administer in about 30 ml of liquid Crushing some drugs alters their time course of activity, stability, or expose potential harm to pharmacy personnel Drugs that are long acting Effexor XR, Cardizem CD, Detrol LA, KDUR, Paxil CR, Seroquel XR Drugs that are enteric coated Ecotrin Depakote Nexium Powerful GI irritant Actonel® Teratogenic (exposure to female pharmacy personnel) Isotretinoin Sublingual Dose Forms Nitroglycerin www.ismp.org/Tools/donotcrush.pdf

9. Medication Reconciliation Medication Reconciliation (MedRecon) Required by Joint Commission in accredited healthcare institutions Designed to help prevent medication errors due to duplications, drug interactions and omissions The process of medication review that is driven by the prescriber primarily During Triage in the ER, a primary list of medications, OTC and herbals that patient is taking is to be generated (along with doses and indications) along with admission orders During each transition of care (i.e. ER to inpatient unit, inpatient unit to critical care (ICU)) a review of this list is mandatory along with current inpatient medication list. Based on this, meds should be discontinued, maintained or changed with Transfer orders Upon Discharge, the primary list is reviewed and a discharge medication list given to the patient explaining any changes to the patient. Discharge medication list is also to be provide to the patient’s primary care provider to update the patient’s care

10. How to report med errors and adverse drug events FDA Medwatch ISMP MERP (medication events reporting program) 1-800-FAILSAF(E) or at www.ismp.org TJC (Joint commission) USP Medmarx: database that tracks and trends med errors and adverse reactions) FDA and CDC VAERS (Vaccine adverse events reporting system) for US licensed vaccines FAERS (FDA Adverse events reporting system) is a database that contains information on med errors and adverse reactions

11. ISMP Medication Error Reporting System (MERP) Used to report medication errors caused by Wrong drug Wrong patient Confusion over dose, dosage form and performing dose calculations Wrong route of administration Used to Report medication errors from around the country Understand the nature of the error and why it may happen Used to provide education to prevent errors from reoccurring

12. ISMP Medication Error Reporting System (MERP) Classification of errors CategoryDefinition ACircumstances can lead to errors (phone ringing during medication entry) BError occurred but did not reach patient (error was caught by pharmacist) CError reach patient but did not cause harm (pt received additonal dose of docusate) DError reach patient, did not cause harm but monitoring was required EError reached patient that require temporary intervention FError reached patient and required hospitalized (TCA overdose) GEror caused permanent harm to patient (gentamicin overdose causes hearing loss)

13. ISMP Medication Error Reporting System (MERP) Classification of errors CategoryDefinition HError that resulting in intervention to sustain life. (Bupivacaine was given IV instead of epidural) IError that results in death. (Massive overdose of pentobarbital to patient or KCL 40 meq IVP)