1. Medical error and Adverse Events
Manar Ezz El- Arab
Parasitology MD,TQM Diploma,CPHQ
TQM-HC AUCians Group Member

2. Objectives Discuss the impact of medical errors.
Discuss different types of medical errors.
Define the relationship between medication error, ADE &preventable ADE.
Approaches to reduce medical errors/medication error..

3. To Err is Human
IOM.1999
IOM is American non governmلاَ يُكَلِّفُ اللَّهُ نَفْسًا إِلاَّ وُسْعَهَا لَهَا مَا كَسَبَتْ وَعَلَيْهَا مَا اكْتَسَبَتْ رَبَّنَا لاَ تُؤَاخِذْنَا إِن نَّسِينَا أَوْ أَخْطَأْنَا
صدق الله العظيمental organization …founded 1970 to help healthcare organization for improve healthcare services

4. What Is The Evidence That Medical Error Is A Problem?

5. Evidence That ME is A Problem
Medications harm at least 1.5 million people per year.
44,000 to 98,000 hospitalized Americans die each year from medical error.
Errors cause more death each year than breast cancer, motor vehicle accidents & AIDS.

6. Evidence That ME is A Problem(Cont.)
The financial burden from these medical errors that is estimated to be in a range of $17 billion to $29 billion annually.
Up to 28% of these events are thought to be preventable .
In addition to the monetary cost of errors, there are physical and psychological costs.

7. What is the medical error?
Errors can be acts of commission, omission or near- misses.
Errors of commission
Errors of omission
Errors of comission :are a situation when the wrong action was taken. For example, prescribing an antibiotic that the patient is known to be allergic to.
Error of omission :are a failure to take the correct action. For example, forgetting to order a cholesterol panel on a patient with diabetes is an example of an omission error.
Near-misses are a situation where an error is just avoided. For example, a nurse is about to administer an antibiotic into a patient, but just before she opens the tubing she notices that it is the antibiotic for the patient in the next room
Near Miss

8. What is the medical error?(Cont.)
Latent error
Adverse Drug Reaction
Active Error
Latent error:in the design, organization ,training or maintenance that lead to operator error and whose effects typically lie dormant in the system for lengthy periods of time.
Adverse drug event :;;harm at normal dose and or /overdoses
Adverse drug reactions:Any unexpected, unintended, undesired, or excessive response to a drug, with or without an “injury”aHarm directly caused by the drug at normal doses, during normal use
Adverse drug Events:An adverse drug event is “an injury resulting from the use of a drug. Under this definition, the term ADE
includes harm caused by the drug (adverse drug reactions and overdoses) and harm from the use of the drug
(including dose reductions and discontinuations of drug therapy).”1 Adverse Drug Events may results from
medication errors but most do not
How does an ADR differ from a side effect or allergy?
An allergy is an adverse drug reaction mediated by an immune response (e.g., rash, hives). A side effect
is an expected and known effect of a drug that is not the intended therapeutic outcome. The term “side
effect” tends to norminalize the concept of injury from drugs. It has been recommended that this term
should generally be avoided in favor of adverse drug reaction
ADRs are a special type of ADEs
Adverse Event

9. The Relationship Among ME, ADEs, & ADRs
Medication Errors
ADEs
ADRs
-Medication errors are more common
than adverse drug events,
-About 25% of adverse drug events are due to
medication errors.

10. Venn diagram is that as some adverse events are preventable and some aren’t, some errors lead to PAEs and some do not. When an error occurs but no adverse event happens, we refer to it as a near miss.
Preventable or avoidable adverse events are a direct result of failure(s) to follow recognized, evidence-based best practices or guidelines at the individual and/or system level…..

11. NCC MERP Index for Categorizing Errors
NCC MERP=national coordinating council for medication error reporting and prevention.

12. Etiology of medical error
1-Fragmentation.
2-Poor communication .
3-Speed.
4-Lack of knowledge.
5-Other Sources of Errors.
-Fragmentation: the use of multiple medical specialists or medical systems to care for one individual – is a large contributor to errors.
-Poor communication between the specialists is commonplace and one specialist often has no idea what the other specialist is doing.
-3-Speed
Unfortunately, when working at high rates of speed the risk of errors is increased.
4-Lack of knowledge:
It is impossible to know everything in health care. Everyday health care providers are faced with situations where they do not know the answer. Sometimes decisions are made, without knowing for sure if the answer is correct. Also, health care providers do not always follow recommended guidelines for screening. Not providing recommendations to patients regarding these screenings results in morbidity and mortality.
5-Other Sources of Errors
Work schedules contribute to errors. Overworked attending physicians, residents and interns contribute to the problem. Nursing shortages often necessitate nurses picking up extra shifts or working a double shift. When health care providers are tired and fatigued, they are more prone to make mistakes.

13. Medication Error (ME)
Any preventable event that has the potential to lead to inappropriate medication use or patient harm during prescribing, transcribing, dispensing, administering, adherence, or monitoring a drug .

14. Types & Classification of Medication Errors

15. Types & Classification of ME
Three major areas for medication error:
Prescribing.
Dispensing.
Administration.

16. The Medication Use System
High-Level of a Medication Use System
Selection
Establish formulary
Prescribing
Assess patient; determine need for drug therapy; select & order drug
Preparing & Dispensing
Purchase & store drug; review & confirm order; distribute to patient location
Administering
Review dispensed drug order; assess patient & administer
Monitoring
Assess patient response to drug; report reactions & errors
Clinician & administrators
All practitioners/nurses, plus patient &/or family
Physician/ prescriber
Pharmacist
Nurse/other health professionals

17. Major Areas for Medication Error
39%
38%
12%
11%
Transcribing means transformation of orders (prescription)to be dispensed…..

18. Prescribing Errors
It is an incorrect drug selection for a patient. Such errors can include the dose, strength, route, quantity, indication, or prescribing contraindicated drug.

19. Prescribing Errors(Cont.)
Contributing factors:
Illegible handwriting.
Inaccurate medication history taking.
Confusion with the drug name.
Inappropriate use of decimal points.
Use of abbreviations (e.g. AZT has led to confusion between Zidovudine & Azathioprine).
Use of verbal order.

20. Prescribing Errors….. Examples
Name That Drug…
6 unties of regular insulin now
Supposed to be: 6 units of regular insulin now
Read as: 60 units
Filled Rx: 60 units

21. Vanco mysin or unasyin??? Capoten or cozzar

22. Dispensing Errors
It is an error that occurs at any stage during the dispensing process from the receipt of a prescription in the pharmacy through to the supply of a dispensed product to the patient.
These errors include the selection of the wrong strength/ product. This occurs primarily when ≥ 2 drugs have a similar appearance or similar name (look-a-like/sound-a-like errors).

23. Dispensing Errors…..Examples

24. Dispensing Errors…..Examples

25. Dispensing Errors…..Examples

26. Administration Errors
Drug administration is associated with one of the highest risk areas in nursing practice.
Drug administration errors largely involve errors of omission where administration is omitted due to a variety of factors e.g. wrong patient, lack of stock.
Other types of drug administration errors include wrong administration technique, administration of expired drugs & wrong preparation administered.

27. Administration Errors(Cont.)
Contributing factors:
Failure to check the patient’s identity prior to administration
Storage of similar preparations in similar areas
Noise, interruptions while undertaking a drug round, & poor lighting .
More than one tablet for a single dose.
Calculation is required to determine the correct dose.
Error

28. Administration Errors…..Example
A patient had an epidural line for pain management & a peripheral IV line containing insulin
The nurse caring for the patient was busy & asked a second nurse to retrieve the next scheduled epidural infusion bag
The second nurse delivered a new bag of insulin to the patient’s bedside
Without checking the label, the primary nurse hung the insulin
infusion to the epidural line

29. Focusing on Error Prevention

30. Can We Do Anything About These Errors?
Step One
See the problem

31. Can We Do Anything About These Errors?
Step Two
Identify
The Risk
& Manage It

32. Identifying Medication Error

33. How Can We Identify The Risk?
High alert medication.
Error prone notations.
Look-a-like & sound-a-like medications.
Tramadol ,toradol…..vincristine and vinblastine

34. High Alert Medications
What are high alert medications?
How can we reduce the error associated with high alert medications?
What are high alert medications: iv insulin,iv k chloride,narcotics , sedatives…….

35. Strategies To Reduce Risk From High-Alert Medications
Limit the access to these medications.
Standardizing the ordering/preparation & administration.
Independent double check at dispensing & administrating phase.

36. Error-Prone Notations
Ambiguous medical notations are one of the most common & preventable causes of medication errors.
Misinterpretation may lead to mistakes that result in patient harm .
Delay start of therapy due to time spent for clarification.

37. Implement “Do Not Use” List
ISMP & FDA recommend that ISMP’s list of error-prone abbreviations be considered whenever medical information is communicated
Complete list is located at:
ISMP= Institute for Safe Medication Practices, FDA= Food and Drug Administration

38. Short List of Error-Prone Notations*
Notations should NEVER be used
Notation
Reason
Instead Use U
Mistaken for 0, 4, cc
Unit IU
Mistaken for IV or 10 QD
Mistaken for QID
Daily
QOD
Mistaken for QID, QD
“every other day”
* Comprises “Do Not Use” list required for JCAHO accreditation

39. Strategies To Reduce The Risk From Error Prone Notations
NEVER use notations

40. Approaches to Reduce Medical Errors

41. Approaches to Reduce Medical Errors
Person-centered approach.
System centered approach.
The Swiss cheese model of systems errors.

42. Approaches to Reduce Medical Errors
Person-Centered Approach
It has been traditional used in analysis of medication errors.
It looks at medication errors as occurring due to human fault including:
Forgetfulness
Poor motivation
Carelessness, not paying attention
Negligence

43. Approaches to Reduce Medical Errors(Cont.)
System-Centered Approach
Errors expected to occur.
Errors are viewed as the end result & not the cause.
There is potential for error & recurring errors in every system, & even the best systems fail.

44. Approaches to Reduce Medical Errors(Cont.)
System-Centered Approach
Solutions are based on the belief that conditions can be changed, rather than focusing on changing humans
Barriers & safeguards should be implemented to help prevent errors
It is essential to focus on how & why the system failed & not on which individual failed.

45. Swiss cheese Model
Defenses and barriers are the best ways to prevent errors in a systems-based approach. Each barrier could be viewed as a slice of cheese. In an ideal word, there would be no holes in the barriers. However, in the real world, the various defenses line up like slices of Swiss cheese. When the holes line up, there is a system failure or an error.
The holes emerge due to either active or latent failures in the system, but usually it is a combination of both. Active errors are unsafe acts committed by those on the front lines. In healthcare, this includes nurse practitioners, physicians, nurses, and pharmacists. Latent errors focus on the conditions surrounding the error. There may have been flaws in the systems that were longstanding. These holes may become apparent when there are local triggering factors based on active errors. In healthcare, types of latent errors include management decisions and organizational processes. Latent failures may be identified and prevented before an error occurs.

46. Always remember “to Err is Human!”

47. THANK YOU
12 April 2018