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Chapter 6: Medication Safety
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Objectives After reading this chapter, you will be able to:
Identify problems patients would experience with over-the-counter purchases and take appropriate action to intervene. Identify commonly prescribed drugs. Identify look-alike and sound-alike medications. Discuss strategies in preventing medication errors.
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Objectives After reading this chapter, you will be able to:
Understand the extent of medical and medication errors and their effects on patient health and safety. Review specific categories and medication errors. List examples of medication errors commonly seen in pharmacy practice settings.
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Objectives After reading this chapter, you will be able to:
Apply a systematic evaluation to search for medication error potential to a pharmacy practice model. Define strategies, including use of automation, for preventing medication errors. Identify the common systems available for reporting medication errors.
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Objectives After reading this chapter, you will be able to:
Compare common over-the-counter and prescription medications. Evaluate the effects of medication errors on patient health and safety. Participate in strategies for preventing and reporting medication errors. Explain categories and common uses of antibiotic classes.
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Over-the-Counter (OTC) Medications
An over-the-counter (OTC) medication is classified as any medication product that can be purchased without a prescription. There are more than 80 therapeutic classes of OTC medications recognized by the FDA.
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Over-the-Counter (OTC) Medications
OTC drugs generally have the following characteristics: Their benefits outweigh their risks. The potential for misuse and abuse is low. Consumers can use them for self-diagnosed conditions. They can be adequately labeled. Health practitioners are not needed for the safe and effective use of the product.
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Safety of OTC Medications
Some OTC medications specifically indicate on their labels that they should not be used for more than a specified number of days without the advice of a healthcare professional.
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Labeling Requirements for OTC Medications
Because consumers purchase and use most OTC medications without the direction of a physician or pharmacist, it is important that all OTC medications contain ample and adequate directions, written in easy-to-understand language for the every-day consumer.
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Potential Problems with OTC Medications
Due to the abundance of advertising for OTC drugs, patients are likely to become confused about the most appropriate choice of product. It is often difficult to recognize and identify the source of symptoms, resulting in an inaccurate self-diagnosis. Some patients may not know the names of the other medications they are taking.
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Homeopathic Medications
Homeopathy is based on the principle of “like cures like,” and uses very small quantities of natural products diluted often in a large percentage of water. Homeopathy is rooted in the idea that natural products stimulate the body’s own immune system.
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Dietary and Nutritional Supplements
Dietary and herbal supplements include vitamins, minerals, and herbs. These supplements are loosely regulated in the United States, with most of the control governed by the Dietary Supplement Health and Education Act (DSHEA) amendments of 1994.
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Medical Errors A medical error is any action, inaction, or decision that contributes to an unintended consequence in healthcare. A medical error may be an inaccurate or incomplete diagnosis, an inappropriate or ineffective treatment of a disease or condition, or an injury, syndrome, or behavior that results from a medical treatment.
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Cost of Medical Errors It is estimated that in hospitals alone, as many as 98,000 people die each year in the United States from medical errors. The total costs related to medical errors that result in injury may reach nearly $30 billion annually. Opportunity costs are also high for medical errors, resulting in increased financial, personnel, and time resources directed toward repeated tests, additional therapy, or prolonged hospital stays.
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Medication Errors Medication error: Prescribing error:
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is under control of the healthcare professional, patient, or consumer. Medication error: Any action in the prescribing decision or prescription-writing process that leads to an unintentional significant reduction in the probability of treatment being timely and effective or an increase in the risk of harm when compared with generally accepted practice. Prescribing error:
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Significance of Medication Errors
In pharmacy, a medication error may occur at any point in the process of selecting, prescribing, transcribing, dispensing, administering, or monitoring drug therapy. Medication errors are among the most common medical errors, and are considered almost entirely preventable. Of the 98,000 people who die as a result of a medical error, 7,000 of the deaths are attributed to a medication error.
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Causes of Medication Errors
Pharmacy technicians can be especially vigilant to monitor, prevent, and report medication errors that occur in pharmacies daily.
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Individual Causes Individuals have unique physiological and social characteristics that influence the effect of medications. It is impossible to predict exactly who will have an adverse reaction to a medication or when it will occur.
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Classification of Medication Errors
occurs when a prescribed dose is not administered as ordered. An omission error occurs when a dose is either above or below the correct dose. A wrong-dose error occurs when a patient receives more doses than were actually prescribed by the prescriber. An extra-dose error occurs when the dose is not administered to the patient by the route intended by the prescriber. A wrong–dosage form error occurs when the drug is not given at the correct time. A wrong-time error
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Reasons for Errors A human-failure error A technical-failure error
occurs at an individual level and is performance-related. Human failures may include a lack of proper training or education, or a failure to follow organizational protocols or policies and procedures. Often, human failures are cited in combination with other factors that contributed to a medication error. A human-failure error results from environmental or location factors or equipment malfunctions. Technical failures may include such issues as lighting, noise, staffing levels, distractions in the pharmacy workspace, or a failure of machinery or equipment to operate correctly. A technical-failure error occurs when rules or policies direct the inappropriate selection, preparation, or administration of a medication. An organizational-failure error
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Medication Errors Incomplete patient information, including patient allergies, other medications patients are taking, previous diagnoses, or lab results Unavailable drug information, including the most up-to-date warnings Miscommunication of drug orders, including poor handwriting, confusion between two similar drug names, misuse of zeros and decimal points, confusion of units, and inappropriate abbreviations Lack of appropriate labeling as the drug is prepared and/or repackaged Environmental factors, including interruptions and distractions for healthcare professionals
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Unapproved Abbreviations
Correct Form, to Be Written Out Completely > “greater than” < “less than” cc “mL” or “milliliter” “micro” or “mc” hs “half-strength” or “at bedtime” IU “International Unit” qd “daily” or “every day” U “units” MgSO4 “Magnesium sulfate” MSO4 “Morphine sulfate”
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Look-Alike Sound-Alike Medications
With tens of thousands of brand and generic medication names available, the chance for confusion is likely. In addition to looking or sounding like other drug names, poor handwriting, similar packaging, or similar therapeutic uses contribute to frequent mistakes in interpreting drug names.
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Medication errors involving look-alike sound-alike medications
Minimize the use of verbal or telephone orders as much as possible. Carefully read the label each time a medication is obtained from the stock shelves or cabinets. Do not merely rely on visual recognition or location to verify a drug product. Legibly print all drug names and doses to prevent confusion.
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Medication errors involving look-alike sound-alike medications
Use “tall-man” lettering if necessary to emphasize differences in drug names, as in the preceding list. Implement storage strategies such as color-coding or boldface labeling for commonly confused medications.
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Clinical Recommendations
Implementing computerized order-entry systems with decision-making support Implementing automated medication-dispensing devices Limiting antibiotic use Improving perioperative management (that is, management of the period of time during and around a surgical procedure) Providing geriatric and pain-consulting services
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The Role of the Pharmacy Technician in Preventing Medication Errors
By diligently maintaining safe working conditions and monitoring for sources of errors, technicians make significant contributions to patient safety.
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Receiving the Prescription
The technician is responsible for verifying that the information provided is complete and legible. In some states, pharmacy technicians may take verbal or telephone orders, and spelling or repeating names is often useful for transcribing accurate information.
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Data Entry for the Prescription
Verify brand and generic names of drugs, match prescribed dose and available strengths and routes of administration, and read the prescription for leading or trailing zeros. Once again verify the information entered against the original prescription to ensure accuracy. Once a prescription label is generated, the label should also be verified against the original prescription.
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Filling the Prescription
Place auxiliary labels on the prescription bottle in a clean, legible manner. If measuring a liquid, use the appropriate size container to measure. If compounding a product, double-check your calculations. If dispensing solid dosage forms, always count the quantity twice. When filling the prescription, make sure all equipment is clean and calibrated, and the workspace is free of distractions or interruptions.
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Final Check After review by the pharmacist, store the medication appropriately until the patient is ready to receive the medication. Avoid errors in storage temperature, light, or humidity that may affect the integrity of the final product.
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Deliver the Prescription
Deliver the medication to the patient, or the nurse in a hospital setting. Once again, verify the patient name and other unique patient identifiers to confirm his or her identity before delivering the final medication.
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Deliver the Prescription
Patients should always know some basic information about their medications. This includes the following: The brand and generic names What the medication looks like Why they are taking it How long they will take it How much to take and how often What to do if they miss a dose Common side effects or precautions of which they should be aware How to store the medication
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Strategies to Prevent Medication Errors
Automation in pharmacy is becoming widespread in both hospitals and community pharmacy practice settings Other systems offer computerized verification of the prescription, in which the computer displays images of the correct tablet that the pharmacist can view compared to what has actually been dispensed Robotic systems have reduced medication errors substantially. In hospitals, the use of an electronic medication administration record (eMAR) reduces medication errors because all medication-related actions, from prescribing to dispensing to administering, are documented electronically, often with a hand-held computer
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Personal Strategies For all pharmacy staff, taking better care of oneself results in improved patient care. Get plenty of sleep, exercise regularly, and eat a balanced diet to maintain workplace focus and stamina. Never be afraid to ask for help. It is imperative that the pharmacy technician take breaks.
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Personal Strategies All steps in the provision of healthcare should be carried out by qualified, well-trained personnel. Remaining up to date on training and education is paramount to the provision of quality healthcare.
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Patient-Related Strategies
Reducing the risk of patient-related medication errors involves providing patients and their caregivers with written medication information—in their primary language, if necessary—and promoting education and awareness.
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Reporting Medication Errors
The Joint Commission released the Sentinel Event Policy in 1996 to promote reporting of medication errors. MEDMARX is an Internet-based system that enables hospitals and healthcare providers to anonymously document and track adverse events for a specific institution. the Medication Error Reporting Program (MERP) is a voluntary and confidential program that enables healthcare professionals to report errors directly.
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Drug Insights: Antibiotics
There are many classes of antibiotics available for the treatment of bacterial infections. The following classes will be reviewed: Sulfonamides Penicillins Cephalosporins Carbapenems Carbacephems Monbactams Tetracyclines Macrolides Ketolides Quinolones Aminoglycosides Miscellaneous antibiotics
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Sulfonamides Sulfonamides, or sulfa drugs, were the first antibiotics and are still in use today. They are bacteriostatic, exerting their effect by preventing the synthesis of folic acid in bacteria.
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Sulfonamides Generic Name Brand Name(s) Dosage Forms Available
Sulfamethoxazole-trimethoprim Bactrim, Bactrim DS, Cotrim, Cotrim DS, Septra, Septra DS IV, oral liquid, tablet Sulfasalazine Azulfidine Tablet Sulfisoxazole Gantrisin Oral liquid, tablet
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Penicillins The penicillins are antibacterial agents with a beta-lactam ring that are bactericidal or they kill susceptible bacteria.
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Penicillins Generic Name Brand Name Dosage Forms Available
Amoxicillin-clavulanate Augmentin Oral suspension, tablet Ticarcillin-clavulante Timentin IV Ampicillin-sulbactam Unasyn Injection, IV Piperacillin-tazobactam Zosyn
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Cephalosporins Cephalosporins work by a mechanism similar to penicillins, inhibiting cell-wall formation in bacteria.
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Cephalosporins The cephalosporins are divided into four generations, each with a different antibacterial spectrum. First-generation cephalosporins are used to treat mild-to-moderate community-acquired infections. Second-generation cephalosporins have broader antibacterial coverage than the first generation, especially against Haemophilus influenza. This generation is used to treat ear infections in children, as well as respiratory-tract infections and UTIs. Third-generation cephalosporins are used to treat severe infections such as UTIs and meningitis. Currently, only one fourth-generation cephalosporin is available. It possesses a broad antibacterial spectrum and is used to treat pneumonia, UTIs, and sepsis.
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Cephalosporins Generation Generic Name Brand Name
Dosage Forms Available First generation Cefadroxil Duricef Capsule, oral liquid Cefazolin Ancef Injection, IV Cephalexin Keflex Capsule, oral liquid, tablet Second generation Cefaclor Ceclor Cefprozil Cefzil Oral liquid, tablet Cefuroxime Ceftin, Zinacef Injection, IV, oral liquid, tablet Third generation Cefdinir Omnicef Ceftazidime Fortaz Ceftriaxone Rocephin Cefpodoxime Vantin Oral liquid Fourth generation Cefepime Maxipime
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Carbapenems, Carbacephems, and Monobactams
Several new drugs and drug classes that are structurally and functionally similar to penicillins and cephalosporins have been developed recently. They are broadly termed “beta-lactams” because of their biochemical structure.
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Carbapenems, Carbacephems, and Monobactams
Class Generic Name Brand Name Dosage Forms Available Carbapenems Ertapenem Invanz Injection, IV Imipenem-cilastatin Primaxin Meropenem Merrem IV IV Cabacephems Doripenem Doribax Loracarbef Lorabid Capsule, oral liquid Monobacatams Aztreonam Azactam
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Tetracyclines Tetracyclines are broad-spectrum antibiotics that block protein formation in bacteria by binding to ribosomes.
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Tetracyclines Generic Name Brand Name Dosage Forms Available
Demeclocycline Declomycin Tablet Doxycycline Vibramycin, Oracea Capsule, IV, oral liquid, tablet Minocycline Minocin, Soladyne Capsule, IV Tetracycline Sumycin Capsule, oral liquid, tablet
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Macrolides Macrolides are bacteriostatic antibiotics. They primarily treat respiratory infections caused by Legionella and other gram-positive bacteria. Like tetracyclines, macrolides inhibit protein synthesis in bacteria by binding to ribosomes.
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Macrolides Generic Name Brand Name Dosage Forms Available Azithromycin
Zithromax, Z-Pak, Zmax Oral liquid, tablet Clarithromycin Biaxin Erythromycin base Eryc, Ery-Tab Capsule, tablet, topical Erythromycin ethylsuccinate E.E.S., EryPed Erythromycin lactobionate Erythrocin Injection Erythromycin stearate Tablet Erythromycin-sulfisoxazole Pediazole Oral liquid
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Ketolides Ketolides also bind to bacterial ribosomes, inhibiting protein synthesis. They inhibit the growth of newly forming ribosomes. Ketolides are used to treat infections in the lungs and sinuses.
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Quinolones Quinolones are rapid-acting bactericidal antibiotics that are effective against most gram-negative bacteria and many gram-positive bacteria. They cause DNA breakage and cell death in replicating bacteria.
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Quinolones Generic Name Brand Name Dosage Forms Available
Ciprofloxacin Cipro IV, oral liquid, otic preparation, tablet, topical;ophthalmic Gatifloxacin Tequin IV, tablet, ophthalmic Levofloxacin Levaquin IV, oral liquid, tablet Moxifloxacin Avelox Tablet, ophthalmic Norfloxacin Noroxin Tablet Ofloxacin Floxin IV, otic preparation, tablet
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Aminoglycosides Aminoglycosides are bactericidal antibiotics and exert their activity by binding to bacterial ribosomes and inhibiting protein synthesis. The use of aminoglycosides is limited to serious, mostly life-threatening infections, sepsis, or peritonitis. Dosing of aminoglycosides is based on monitoring blood levels of the drug in conjunction with patient response.
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Aminoglycosides Generic Name Brand Name Dosage Forms Available
Amikacin Amikin Injection, IV Gentamicin Garamycin Injection, IV, ophthalmic preparation Neomycin Mycifradin, Neo-Fradin, Neo Rx Oral liquid, topical preparation Streptomycin None Tobramycin Nebcin
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Miscellaneous Antibiotics
Class (If Applicable) Generic Name Brand Name Dosage Forms Available Streptogramins Quinupristin-dalfopristin Synercid IV Cyclic lipopeptides Daptomycin Cubicin Vancomycin Vancocin IV, capsule Clindamycin Cleocin Capsule, injection, IV, oral liquid, topical preparation Metronidazole Flagyl Capsule, IV, tablet, topical preparations, vaginal preparations Pentamidine NebuPent, Pentam Injection, IV, inhalation Oxazolidinones Linezolid Zyvox IV, oral liquid, tablet
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