1. Day 3: Preventing mistakes, errors and making corrections – Implementing CAPA
11/17/2018

2. This results in high cost (emotional and financial)
Introduction
Medication errors responsible for numerous adverse outcomes, including death
This results in high cost (emotional and financial)
A recent report from the Institute of Medicine has revealed that a large number of patients die unnecessarily each year due to errors committed while delivering care. A large number of these errors are related to medication use. In fact, it is estimated that as many as 30% of all hospital admissions are due to the improper use of medications. These negative outcomes carry a high cost, first emotional to all those involved, then financial.
It is apparent that most health care providers are not fully aware of their responsibilities in the medication use process. This educational module will help define the roles and responsibilities of all providers in the medication use process.

3. General framework for handling dispensing errors
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4. EVALUATION AND GRADING OF SEVERITY
NCCMERP Index for Categorizing Medication Errors.10 Reprinted with permission. Copyright © 2001, National Coordinating Council for Medication Error Reporting and Prevention. All rights reserved.
EVALUATION AND GRADING OF SEVERITY

5. At which stage do Errors Occur. Prescribing. 39% Transcribing
At which stage do Errors Occur? Prescribing 39% Transcribing % Dispensing 12% Administering 38%
Prescribing
Transcribing
Dispensing
Administering
39%
11%
12%
38%
Where do errors occur?
Leape and colleagues3 reported in 1995 that medication errors occur at different concentrations depending on the stage of the medication or prescribing process. Most medication errors occur during physician ordering (39%) and medication administration (38%).
INVESTIGATION AND STAGING

6. Prescribing errors causes and factors
There is an increasing body of knowledge
New therapeutic entities
Drug interactions
Allergies database
Food-drug interactions
Post-marketing data
Insufficient training in clinical pharmacology and therapeutics
Inadequate internship and mentoring into effective prescribing
Know it all attitude
Overwork, inadequate time for refection and good decision-making
Distractions
A continuously larger number of medications continue to be released on the market. In addition to many look-alike and sound-alike therapeutic entities, the potential for drug interactions and adverse reactions continues to increase. It is virtually impossible for a prescriber to remember or know all the potential dangers associated with each medication. This is why a collaborative effort of various health care providers is important.
With the help of computerized databases, providers are able to minimize the likelihood of adverse drug reactions and interactions.
All providers of care are responsible for providing post-marketing data (especially adverse drug reactions) for all medications.

7. Summary on causes of prescribing errors
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8. Written Medication Orders: Illegible Handwriting
16% of physicians have illegible handwriting
Common cause of prescribing/dispensing errors
Delays medication administration
Interrupts workflow
Prescription for Illegible Handwriting:
The written medication order is the first place in which a prescribing error may occur.1
For example, As a result of poor handwriting, written orders require extra time to interpret. Sixteen percent of physicians have illegible handwriting.1 Worse, illegible handwriting on medication orders is a common cause of prescribing errors, and patient injury and death have resulted. There may also be legal ramifications to illegible handwriting. According to a 1997 American Medical Association report, medication errors related to misinterpreted physicians’ prescriptions were the second most prevalent and expensive claim listed on malpractice cases filed over a 7-year period.4 Illegible orders may also lead to delays in the administration of medications. In order to clarify these illegible orders, the health care practitioner’s work flow is typically interrupted.1
Take Home Points:
In order to prevent prescribing errors, written medication orders should:
be legible;
include complete information;
consider patient-specific information; avoid abbreviations;
express weight, volumes, and units using the metric system;
avoid decimals;
deal cautiously with drug names;
and include the medication's purpose.

9. Poor handwriting contributed to a medication dispensing error that resulted in a patient with depression receiving the antianxiety agent Buspar 10 mg instead of Prozac 10 mg

10. A hypertensive patient accidentally received Vasotec 20 mg instead of Vantin 200 mg when a pharmacist misread this prescription.

11. The importance of including the medication strength on a medication order is illustrated by a case in which a physician prescribed the medication above.
Since the order did not specify a strength or directions, a pharmacist misread the prescription as Fiorinal, a combination ingredient oral analgesic, instead of Florinef (fludrocortisone), for Addison’s Disease. The patient received the wrong medication for over a month and was finally hospitalized with severe electrolyte imbalance.
Had the strength been written (Florinef is available in 0.1 mg tablets) along with the directions (two tablets daily was intended), it’s doubtful that the pharmacist would have misread the prescription. Fiorinal is not a 0.1 mg tablet and rarely, if ever, is it prescribed for use on a “once-a-day” basis. Also, including both the brand and generic name on prescriptions would help to prevent this type of error. Had “Florinef (fludrocortisone)” been prescribed, it’s clear that this error would not have happened.
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management;

12. THE ABBREVIATION PROBLEMU ug
q.d.
qod SC
TIW

13. Written Medication Orders: Do Not Use Abbreviations
Drug names
“QD” or “OD” for the word daily
Letter “U” for unit
“µg” for microgram (use mcg)
“QOD” for every other day
“sc” or “sq” for subcutaneous
“a/” or “&” for and
“cc” for cubic centimeter
“D/C” for discontinue or discharge
Although believed to save time, abbreviations actually waste time and increase the potential for medication errors.1 Nonstandard abbreviations should be avoided. The following abbreviations are consistently misunderstood and should never be used:1, 7
Drug name abbreviations can sometimes represent more than one drug. “AZT”, for example, has been used for both zidovudine and azathioprine. “CPZ” can mean either Compazine® or chlorpromazine. The abbreviation HCTZ 50 mg (hydrochlorothiazide) has been misinterpreted as HCT 250 mg (hydrocortisone).
Any abbreviation for the word daily. QD, although frequently used, has been interpreted at QID. OD for once daily can also be interpreted as right eye.
The letter “U” for unit. This is one of the most dangerous abbreviations. “U” has been misinterpreted as a zero, four, six, or seven. In some cases, it has been confused for “cc”. Errors associated with “U” typically involve insulin, penicillin, or heparin.
“µg” for microgram (use mcg).
“QOD” for every other day. If the “O” becomes squeezed QOD can be misinterpreted as QID.
“SC” or “SQ” for subcutaneous.
“&” for “and”.
“cc” for cubic centimeter.
“D/C” for discontinue or discharge.
Note: A complete list of abbreviations and dose designations that have been involved in medication errors is available at:
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management;
Jones EH. Clev Clin J Med 1997; 64:

14. Dosage problem
Resist the temptation to abbreviate drug names. In this prescription above, the common abbreviation for “hydrochlorthiazide 50 mg’ was misread as “hydrocortisone 250 mg.” In another case, an order for “AZT 100 mg” (a common abbreviation for the antiretroviral drug zidovudine - Retrovir) for a patient with AIDS, was misinterpreted as azathioprine (Imuran), an immunosuppressant. The potential harm in giving azathioprine to a patient with AIDS is obvious.

15. Unit problem
This abbreviation (“U” for the word “unit) was misread as a zero which led to a patient receiving a ten-fold overdose of insulin.

16. A line on a prescription form on the colchicine order above obliterated the decimal point, making the dose look more like 10 mg than 1.0 mg.
The Synthroid order looks more like 1 mg than 0.1 mg. After receiving an overdose for several weeks, the patient was admitted to the hospital for hyperthyroidism and weight loss. The medication error was recognized during a medical history when the patient showed a physician the prescription container label. At the time, tablets of 0.5 mg were marketed so the error was made using only two tablets per dose.

17. Written Medication Orders: Decimals
Avoid whenever possible
Use 500 mg for 0.5 g
Use 125 mcg for mg
Never leave a decimal point “naked”
Haldol .5 mg  Haldol 0.5 mg
Never use a terminal zero
-Colchicine 1 mg not 1.0 mg
Space between name and dose
Inderal40 mg  Inderal 40 mg
Decimal points are a common source of medication errors. They can easily be missed on lined order sheets, carbon and no-carbon-required (NCR) forms, and faxes. Overdoses can occur when a decimal point is missed. They should, therefore, be avoided whenever possible. It would be best to write “500 mg” instead of “0.5 g” or “125 mcg” instead of mg.” 1
If a decimal point is absolutely necessary, it should never be left “naked.” In order to improve the visibility of the decimal point, numbers less than 1 should always be preceded by a zero. For example, an order for Haldol® .5 mg was misinterpreted as Haldol® 5 mg. On the other hand, whole numbers should never be followed with a decimal point and a zero. For example, colchicine 1.0 mg may be misinterpreted as colchicine 10 mg if the decimal point is not clear.7,9
A space should always be place between the name of the medication and the dose, as well as, between the dose and the units. For example, an order written Inderal40 mg was misinterpreted as Inderal 140 mg because a space was left out. 9

18. Written Medication Orders: Drug Names
“Look-Alike” or “Sound-Alike” Drug Names
“Confirmation Bias”
Addition of Suffixes
Example Adalat CC 30 mg vs. Adalat 30 mg
Drug names that look- or sound-alike increase the risk for medication errors. When these look-alike or sound-alike drugs have overlapping dosage ranges the potential for errors may be even greater.1
“Confirmation bias” is a common cause of name mix-ups. For example, a health care practitioner looking at a poorly written medication order may see the name of a drug with which he or she is most familiar and overlook any evidence to the contrary.1 Computers may help decrease the risk of confirmation bias and drug name mix-ups. Some pharmacy computer systems have software to alert pharmacists about problem name pairs and some of the pharmacy benefit managers are beginning to alert pharmacists during the prescription adjudication process. For example, a note reminds the pharmacist entering an order for Norvasc® that it often looks like Navane®. The pharmacist can then confirm the order if necessary.
Another potential medication prescribing error, related to drug name, may occur when a suffix is added to an already marketed drug name. For example, verbal and written orders for extended release Procardia XL® have been interpreted as Procardia® SL. 1, 10 Sometimes suffixes are erroneously left off of prescription orders. For example, if a prescription for Depakote ER is accidentally written as Depakote, the patient would receive the wrong dosage form.
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management;
Cohen MR. Am Pharm 1992; NS32: 21-2.

19. Look-alike And Sound-alike Drug Names
Zyrtec®
Zantac®
Prilosec®
Plendil®
Neoral®
Nizoral®
Lomotil®
Lamisil®
Fosamax®
Flomax®
Cardura®
Cardene®
Lorazepam
Alprazolam
Accutane®
Accupril®
This is a list of some look-alike and/or sound-alike drug name pairs that have been reported to the United States Pharmacopeia Medication Error Reporting Program. These names may not sound alike when they are read or look alike in print; however, when handwritten or communicated verbally they can be confused.
A more complete list of these drug name pairs can be obtained at

20. Dispensing Incidents/ Errors
Dispensing errors, significant other errors, omissions, incidents, or other non-compliances, including complaints of a non-commercial nature arising both within and external to the pharmacy, may be the subject of investigation.
Pharmacists should therefore follow a risk management procedure, including appropriate record keeping.
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24. Dispensing Errors: Common Causes
Work environment
Workload
Distractions
Cluttered, disorganized work areas
Use of outdated or incorrect references
The most common causes of dispensing errors are related to either the work environment or the use of outdated or incorrect references. Factors in the work environment that may contribute to dispensing errors include work load, distractions, and the design of the work area. 1

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27. Dispensing Errors: The Numbers
One study reported a 98.3% accuracy in dispensing medications; or 1.7% inaccuracy rate.
Based on the above figure, how many dispensing errors cannot you predict from your pharmacy?
You need to know how many prescriptions your pharmacy fills per day.

28. Most Prevalent Dispensing Errors
Dispensing incorrect medication, dosage strength, or dosage form
Dosage miscalculations
Failure to identify drug interactions or contraindications
The top three dispensing errors include (1) dispensing an incorrect medication, dosage strength, or dosage form, (2) dosage miscalculations, and (3) failure to identify drug interactions or contraindications.1
The first step to preventing dispensing errors is to identify the causes. Then, new policies and procedures can be instituted and the staff can be educated. 1

29. Types of Dispensing Errors
Commission versus omission
Mistake versus slip
Potential versus actual
The are various ways dispensing errors can be classified:
Commission/Omission- Dispensing the wrong drug or dose would be an error of commission. Whereas, failure to counsel a patient or screen for drug interactions would be considered an error of omission. 1
Mechanical/Judgmental- Mechanical errors are those which occur during the preparation and processing of a prescription. Judgmental errors, on the other hand, are those involving patient counseling, screening, or monitoring. 1
Slip/Mistake- Slips are often caused by poor design or distraction. An error related to reliance on automatic behavior, after a distraction has occurred or poor system design, would be considered a slip. An error due to conscious deliberation, perhaps because of a lack of knowledge, would be considered a mistake. For example, a mistake may occur if a pharmacist does not know that there are 2 strengths of Prozac® available. 1, 3
Potential/Actual- Potential errors are those which are detected and corrected prior to the administration of the medication. Whereas, actual errors are those which actually reach the patient. 1