1. 35
Medication Errors

2. State Standard
17) Identify strategies for preventing medication errors by distinguishing medications that either look alike or sound alike, such as Ceftin, Cefotan, Cefzil, Rocephin and Cipro. Include strategies related to recognizing high-alert/high-risk medications such as Sporanox for patients who have ventricular dysfunction.

3. Objectives Student will be able to… Define what a medication Error is.
Explore the primary reason for medication errors
Identify common types of medication Errors.

4. Medication Errors Defined as:
"Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer."

5. Medication Errors Defined as:
"Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

6. Medication Errors
Four primary reasons for errors defined in 1848 and still exist today
Poor handwriting of prescribing physicians
Improper and mistaken use of medical and pharmaceutical abbreviations and selection of wrong drugs with various synonyms

7. Medication Errors
Four primary reasons for errors defined in 1848 and still exist today
Poor conditions of the environment making it easy to lose concentration while dispensing and selecting the medications correctly
Poor training of pharmacy staff and lack of follow-through by the pharmacist in the dispensing process

8. Medication Errors Five rights of medication administration
Right patient
Right drug
Right route
Right dose
Right time

9. Types of Errors
American Hospital Association lists some common types of medication errors.
Incomplete patient information
Unavailable drug information
Miscommunication of drug orders

10. Types of Errors
American Hospital Association lists some common types of medication errors.
Lack of appropriate labeling as a drug is prepared and repackaged into smaller units
Environmental factors that can distract health professionals from their medical tasks

11. Types of Errors Unordered or unauthorized drug error
Administration of a dose of medication that was never ordered for that patient.
Also called a wrong drug error

12. Types of Errors Extra dose error Omission error
A dose is given in excess of the total number of times ordered by the physician.
Omission error
No attempt made to administer the dose

13. Types of Errors Wrong dose error Wrong route error
Dose contains wrong number of preformed dosage units or was more than 17% greater or less than the correct dosage.
Wrong route error
Dose administered by different route than ordered

14. Types of Errors Wrong time error Wrong dosage form error
Dose given 30+ minutes (or 60+ minutes depending on site) before or after scheduled administration time without an acceptable reason
Wrong dosage form error
Administration of dose form different from what the physician specified or implied

15. Types of Errors Age-related errors
Pediatric patients especially vulnerable to errors, particularly incorrect dosage based on computation errors and wrong dosage intervals
Check and recheck for age and weight.
OTC products may not contain pediatric dosing indications or guidelines.

16. Statistics
Each year
More people die each year from medical errors than motor vehicle accidents, breast cancer, or AIDS.

17. Statistics Each year Around 98,000 deaths occur from medical errors.
7,000+ (about 7%) from medication errors
Average rate for medication errors is 1.8 (nearly 2 Rx/100 dispensed) = 60 million errors/3 billion Rx filled annually in the U.S.

18. Statistics Top three drug classes for medication errors
Central nervous system
Opioid analgesics
Sedatives/hypnotics/anxiolytics
Anticonvulsants

19. Statistics Top three drug classes for medication errors Cardiovascular
Beta-blockers
Diuretics
Calcium-channel blockers

20. Statistics Top three drug classes for medication errors
Hormones/synthetics/modifiers
Insulin
Antidiabetic agents
Adrenal corticosteroids

21. Technology and Errors Computer problems or errors
Shorthand directions mistyped, then misread
Computer doesn't always recognize abbreviations being used.
Choosing wrong drug from database
Choosing wrong strength from database

22. Technology and Errors Read carefully
As you type, again when label is printed. Compare original Rx to patient record and printed label.

23. Technology and Errors Triple check process helps avoid errors
Read what is typed carefully
As you type
Again when label is printed
Compare original Rx to patient record and printed label.
Read label again before pharmacist does final check.

24. Look-Alike–Sound-Alike Drugs
Drugs with similar spelling or similar sounding names can be confusing.

25. Table 35-1 Examples of Look-Alike–Sound-Alike Drugs

26. Look-Alike–Sound-Alike Drugs
Generic drug manufactures use standard design on label so similar words look alike, causing confusion.
FDA created "Tall-Man Lettering" to help flag potential problem medications.
Examples
EPINEPHrine and ePHEDrine
PREDnisone and predNISOLONE

27. Activity Complete drug cards for the following… Tolterodine (Detrol)
Ranitidine (Zantac)
Famotidine (Pepcid)
In reference to St. 17, pretend that you are an experienced pharmacist, and create a teaching plan for a new pharmacy technician that outlines types of medication errors, common reasons for errors, and at least 20 common look-alike-sound-alike drugs. Your teaching plan should be at least a page in length, and include objectives and an activity.

28. Preventing Medication Errors

29. State Standard
16) Outline in a written or digital presentation industry standards surrounding medication safety. Cite information obtained from textbooks, online and print pharmacy journals, and related websites. Include at minimum the following:
a. Error prevention strategies for data entry (e.g., prescription or medication order to correct patient)
b. Patient package insert and medication guide requirements (e.g., special directions and precautions)
c. Issues that require pharmacist intervention (e.g., DUR, ADE, OTC recommendation, therapeutic substitution, misuse, missed dose)
d. Common safety strategies (e.g., tall man lettering, separating inventory, leading and trailing zeroes, limited use of error-prone abbreviations)

30. Objectives Students will be able to..
Identify the pharmacy technicians role in preventing medication errors.
Identify roles of the pharmacy in preventing medication errors.
Explore real world medication errors and their consequences.

31. Preventing Medication Errors
Role of the pharmacy technician
Pharmacy technicians are responsible for many activities involved in filling and dispensing prescription medications.
Evolving role means more responsibilities that were once only performed by pharmacist.
Pharmacy technicians must ensure that all medication is correct BEFORE the final check by the pharmacist.

32. Preventing Medication Errors
Hospital-wide action to prevent medication errors
Adequate staffing
Formulary system with therapeutic uses and evaluations for pediatric uses of certain drugs

33. Preventing Medication Errors
Hospital-wide action to prevent medication errors
Track medication errors
Formal systems
Report errors to families
Encourage team environment

34. Preventing Medication Errors
Pharmacy actions to prevent medication errors
Technology errors
Use past errors to suggest improvements to IT department or pharmacy manager.

35. Preventing Medication Errors
Pharmacy actions to prevent medication errors
Concentration errors
Understand patients can lash out because they don't feel well, especially at peak times.
Don't be overcome by stress.
During peak hours, take extra care.

36. Preventing Medication Errors
Pharmacy actions to prevent medication errors
Ultimate tool is education.
Pharmacist, pharmacy technician, and patient all benefit.
Continuing education for pharmacy staff should be mandatory.

37. Preventing Medication Errors
Pharmacy actions to prevent medication errors
Ultimate tool is education.
Training in automated pharmacy technology and certification courses (IV, compounding, etc.)
Keep up with news reports, safety advisories, continuing education programs.

38. Preventing Medication Errors
Pharmacy actions to prevent medication errors
Recheck calculations against weight-based dosage ranges
Reconfirm confusing orders with physician/pharmacist
Check for current allergies and drug compatibilities

39. Preventing Medication Errors
Pharmacy actions to prevent medication errors
Prepare drugs in a clean environment and avoid interruptions during preparation
Obtain the original written order before dispensing

40. Preventing Medication Errors
Pharmacy actions to prevent medication errors
If possible, use a unit-dose or ready-to-use medication form
Do not store sound-alike or look-alike drugs next to each other

41. Preventing Medication Errors
Pharmacy education and communication
Best practices should include:
Checking medication calculations with another team member, especially if unusual in dosage or amount
Confirming patient identity and pertinent information before dispensing
Educating patients or caregivers about medication before dispensing

42. Preventing Medication Errors
Pharmacy education and communication
Best practices should include:
Implementing tracking system for errors and communicate with all staff involved on a regular basis to review
Answering all questions from caregivers and listen attentively to them
Double-checking all orders

43. Preventing Medication Errors
Pharmacy education and communication
Best practices should include:
Always using proper dispensing utensils, such as droppers or medicine cups; do not use inexact utensils, such as household teaspoons, for measurement or dispensing.

44. Monitoring and Reporting Errors
Institute of Medicine (IOM) recommends e-prescribing to avoid errors from illegible handwriting and abbreviations.

45. Monitoring and Reporting Errors
Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) includes e-prescription incentives.
Electronic prescribers could earn a 2% incentive payment during the current year.

46. Case Studies For each case study, consider:
What was the cause of the error?
What was the impact of the error?
What could have been done to prevent the error?

47. Case Studies Glynase/ritalin mixup
Seven-year-old patient in South Carolina suffered permanent brain damage from Glynase 6 mg instead of Ritalin that was prescribed.

48. Case Studies mcg/mg mixup
Pittsburgh pharmacist mistranscribes phone Rx confusing milligrams and micrograms.
Patient receives 2,000+ times recommended max dose, becomes totally disabled.

49. Case Studies Cycrin/Coumadin Mixup
Florida pharmacist dispenses Cycrin (female hormone) instead of Coumadin. Patient suffered stroke, heart attack, permanent coma.

50. Case Studies Tainted IV bags
Compounding pharmacy in Birmingham, AL, source of Serratia marcescens outbreak affecting 19 patients in six hospitals

51. Case Studies Emily Jerry
18-month-old diagnosed with a yolk sac tumor. Cancer cured but patient died from final chemotherapy treatment. Pharmacy technician used 23.4% sodium chloride solution instead of less than 1%. Pharmacist was distracted by personal phone call and approved solution.

52. Activity Complete drug cards for the following…
Diltiazem (Cardizem)
Budesonide+ Formoterol (Symbicort)
Codeine + Guanifenesin (Robitussin AC syrup)
Per St. 16 Complete a presentation over prevention of medication errors. Guidelines are on the next slide.

53. * PowerPoint presentation Google Slides (present Friday) 2-3 minutes in length
16) Outline in a written or digital presentation industry standards surrounding medication safety. Cite information obtained from textbooks, online and print pharmacy journals, and related websites. Include at minimum the following:
a. Error prevention strategies for data entry (e.g., prescription or medication order to correct patient)
b. Patient package insert and medication guide requirements (e.g., special directions and precautions)
c. Issues that require pharmacist intervention (e.g., DUR, ADE, OTC recommendation, therapeutic substitution, misuse, missed dose)
d. Common safety strategies (e.g., tall man lettering, separating inventory, leading and trailing zeroes, limited use of error-prone abbreviations)

54. Summary Medication error rate is rising.
Know where medication errors occur.
Make a conscious effort to reduce medication errors.
Report errors to appropriate agencies so everyone can learn from them.
Reports can be anonymous or with full details.