1. Medication Errors Chapter 11
NEED TO UPDATE EDITION AND COPYRIGHT INFORMATION

2. Overview
Medication error – any preventable event causing or leading to inappropriate medication use or patient harm
Involve health care professionals, patients, or consumers
Occur during manufacturing, prescribing, transcribing, dispensing, and administering medications

3. Occurrence of Medication Errors
May happen anywhere
Approximately 98,000 Americans die each year as a result of medical errors, with nearly 7,000 of these attributable to actual medication errors
(continues)

4. Occurrence of Medication Errors
Most errors occur during ordering (39%) and administration (38%), with the rest divided between transcription and pharmacy dispensing

5. Prescribing Errors
Most medication errors occur when physicians, nurse practitioners, physician assistants, dentists, and pharmacists order prescriptions
Illegible handwriting can cause the wrong drug to be given

6. Dispensing Errors
Medication errors during dispensing can be made by pharmacists or pharmacy technicians
The pharmacy technician must be skilled in:
Generic and trade names of drugs
Performing dosage calculations
Awareness of sound-alike and look-alike drugs
Aseptic technique

7. Administration Errors
During administration of medication, errors may occur due to:
Misuse of infusion pumps and other parenteral delivery systems
Memory lapses
Faulty drug identification or dose verification
Wrong drug, dose, patient, time, route, technique, or information on the patient chart

8. Rights of Drug Administration

9. The Patient’s Role in Medication Errors
They may occur when patients self-administer drugs at home
Patients must be informed regarding their:
Condition and treatment plan
Prognosis
Risks and benefits
Alternative treatments
Complications that may occur
Other vital pieces of information

10. Medications of “Highest Alert”
According to the Institute for Safe Medication Practices (ISMP), these medications are of “highest alert”:
Insulin
Narcotics and opiates
Potassium chloride injections
Heparin
Concentrated sodium chloride (>0.9%)

11. Risk Factors for Medication Errors
Risk factors include:
Fatigue
Noise and stress
Poor lighting and management
Illegible handwriting
Inadequate patient monitoring
Lack of drug knowledge or patient information
Rule violations
(continues)

12. Risk Factors for Medication Errors
Risk factors include:
Problems with herbal remedies and OTC drugs
Problems with medications sold over the Internet
Illegal drugs

13. Human Factors Human factors related to medication errors include:
Lack of attention to details
Failure to recognize certain facts
Choosing incorrect medications
Failing to remember something concerning the medication or patient
Making incorrect choices about what actions are to be taken

14. Fatigue
Fatigue has many effects that can allow medication errors to occur, including:
Slowed reaction times
Reduced accuracy
Inability to recognize changes in the patient
Lapses of attention
Impaired communication ability
Memory lapses
Decreased energy

15. Noise
Internal and external noise can interrupt the concentration of health care workers and cause medication errors
Types of noise include:
Outside construction and traffic noise
Interior repair work, conversations, cell phones ringing, and overhead music systems

16. Poor Lighting
Adequate, bright lighting has been proven to decrease medication errors by increasing alertness and the ability to read information more accurately
Poor lighting may cause labels to be misread

17. Poor Management
If pharmacy technicians are not adequately supervised due to staff shortages, they may make errors that will go unchecked by pharmacists or other personnel
Other areas of poor management include:
Not addressing air-conditioning problems
Not addressing unhealthy conditions
Not addressing anything that may cause workers to have a lack of focus

18. Stress Stress is often linked to a variety of medication errors
Stress causes distraction and lack of focus
Stress may be caused by:
Personal and family problems
Sickness
Poverty
Conflicts with staff members
Dealing with upset or angry patients

19. Illegible Handwriting
Illegible handwriting has been documented as the second most prevalent cause of medication errors
Methods of counteracting illegible handwriting include:
Writing prescriptions more slowly and clearly
Dictating or typing prescriptions
Reviewing prescriptions for accuracy and clarity
Discussing prescriptions with other health care staff members

20. Inadequate Patient Monitoring
Health care professionals must monitor patients to ensure safe medication administration and outcomes
Vital signs and levels of consciousness can be verified
Pain scales are printed charts that patients can view and then respond to
Diagnostic tests are also important for patient monitoring

21. Lack of Drug Knowledge
Patients who do not understand their medications and the requirements for their use may inadvertently harm themselves
Caregivers must likewise be knowledgeable
Patients should be encouraged to ask questions about their medications

22. Lack of Patient Information
Patient information that is essential in reducing medication errors includes:
Age
Sex
Pregnancy
Diagnoses
Allergies
Height and weight
(continues)

23. Lack of Patient Information
Patient information that is essential in reducing medication errors includes:
Lab test values and diagnostic study results
Vital signs
Patient identity
Ability to pay for prescriptions

24. Rule Violations
Health care professionals must follow the rules of their health care practice setting
For example, physicians are required to verify allergy history, and pharmacists are required to counsel patients
During administration of medications, the “seven rights” of administration must be followed

25. Problems with Herbal Remedies
Herbal remedies may interact dangerously with certain medications prescribed by a physician, dispensed by a pharmacist, or administered by a nurse
It is vital to ask patients what types of herbal remedies they are taking – they must list all of them

26. Problems with OTC Drugs
Lack of knowledge of drug interactions with prescribed medications

27. Problems with Medications Sold over the Internet
Patients often purchase medications via Internet web sites in order to get them more cheaply
Often, these web sites originate in other countries that use different formulations
They may not be approved by the FDA, and may even be illegal to purchase, as well as being potentially dangerous

28. Illegal Drugs
Some patients use illegal drugs, which they often do not report to their physicians
The potential for interactions with prescribed drugs is dangerous
For example, a sedative prescribed for a patient using heroin or cocaine may severely harm the patient

29. Dangerous Abbreviations and Numerical Terms
Medication errors frequently occur when prescribers use abbreviations
The “do not use” list includes:
U – Write out the word “units” instead
IU – Write out “international units” instead
QD – Write out the word “daily” instead
SC or SQ – Write out the word “sublingual” instead
D/C – Write out “discharge” or “discontinue” instead
HS – Write out “half strength” or “hour of sleep” instead

30. Leading Zeros and Trailing Zeros
Leading zeros should be used before decimal points, as follows:
Write “0.2 mg” instead of “.2 mg”
Trailing zeros should not be used after decimal points, as follows:
Write “2 mg” instead of “2.0 mg”

31. Avoiding Medication Errors
Prevention must be the most important priority of health care professionals, and they must educate patients
Keep these in mind:
Confirm patient’s identity
Verify the original prescription, medication calculation, and patient allergy history
Communicate concerns to the pharmacist
Inquire if the patient has questions for the pharmacist
Maintain continuing education

32. Medication Error Reporting
The reporting of medication errors and problems with products must be done whenever they occur, even though the reporting process is voluntarily
There are two medication error reporting systems:
FDA MedWatch Program
U.S. Pharmacopeia’s (USP) Medication Error Reporting Program

33. FDA MedWatch Program
MedWatch allows reporting of medication errors or product problems by phone, fax, and through the Internet
It also provides important and timely clinical information, including:
Prescription and OTC drugs
Biologics
Medical and radiation-emitting devices
Special nutritional products

34. USP’s Medication Error Reporting Program
This program provides the sharing of medication error experiences through a nationwide network
It was designed to recognize circumstances and causes of actual and potential errors
Reporting is confidential, and can be anonymous

35. Minimizing Liability
Upon detecting an error in dispensing, the pharmacy technician must take all necessary steps to rectify it promptly and notify the pharmacist immediately
The pharmacist should inform the patient and prescribing physician immediately

36. Negligence / Malpractice / Penalties
Pharmacy laws protect the public by ensuring double-checking of results of the prescribing process and overseeing use of medications
Negligence is the failure to do something that a reasonable person might do, or doing something that a reasonable person might not do
(continues)

37. Negligence / Malpractice / Penalties
Malpractice is negligence performed by a professional
Penalties may include restrictions on practice, suspension of practice, fines, revocation of practice, and jail sentences