1. BSc. Pharmacy, MSc. Clinical Pharmacy, PhD. Student
Communication Skills
Medication Safety By
Dr. Vian Ahmed
BSc. Pharmacy, MSc. Clinical Pharmacy, PhD. Student

2. Case Study
B.A., a 78-year-old female, visited her GP for a refill of her “blood thinner”—Coumadin 5 mg. Her physician told her to take one-half a tablet daily for 4 days & then 1 tablet daily thereafter.
Her physician wrote:
Coumadin 5 mg.
2½ mg q d x 4 d; 1 tab q d. #30.

3. Case Study Continued…..
J. C., the pharmacist who filled the prescription, typed 2½tablets daily for 4 days & then one tablet daily on the prescription label.
Unfortunately, J. was too busy to speak with B. when she picked up her prescription.
At home, B. forgot what her physician said & followed J.’s instructions.

4. Case Study Continued…..
Thus, she took 2½ tablets (5 × the intended amount).
Going into her 4th day of this treatment, B. died of massive hemorrhaging.
This situation is based on an actual experience.

5. Medication errors
Defined as any error in the prescribing, dispensing, or administration of a drug, irrespective of whether such errors lead to adverse consequences or not.
Are the single most preventable cause of patient harm.

6. Medication Error
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 provider, patient, or consumer”
It can cause;
Physical harm
Lost of patient’s confidence in health care system
reduced adherence with prescribed therapy
Increased use of alternative therapies

7. Possible Causes of Medication Error
Distractions & noise that interfere with clear transmission of the message.
Heavy accents & language differences.
Use of terminology that others do not understand.
Speaking too rapidly.

8. Possible Causes of Medication Error
5. Medications that sound alike when spoken (Zantac vs. Zyrtec). 6. Numbers that sound alike (15 vs. 50; 19 vs. 90). 7. Poor handwriting. 8. Medication names that look alike when written out (Celexa vs. Celbrex or Bisoprolol 10 mg & Buspirone 10 mg)

9. Possible Causes of Medication Error
9. Misplaced zeroes & decimal points in dosing instructions (.5 vs. 0.5; 1.0 vs. 10).
10. Unclear abbreviations within patient care instructions.

10. Specific Strategies to Minimize Errors
By;
Written communication rather than verbal communication.
Computerized physician order entry (CPOE) systems.
Check the contents & label of the prescription.

11. Specific Strategies to Minimize Errors
4. Bar coding 5. Tall Man Lettering 6. In verbal orders over the phone, repeat all components & place a checkmark for each component.