Medication Safety & Medication Errors Part I PHCL 311

Name: Medication Safety & Medication Errors Part I PHCL 311
Uploaded: 2017-08-16T15:27:34+00:00
Duration: PTM26S44
Channel: Amelia Simon
Description: Medication Safety & Medication Errors Part I PHCL 311

Medication Safety & Medication Errors Part I PHCL 311
Hadeel Al-Kofide MS.c

Topics to be covered today
Introduction The evidence that medication error is a problem Definitions The relationship between medication error, ADE & ADE Classifications & types of medication error Reasons for medication errors How to prevent medication error

Introduction The goal of drug therapy is the achievement of defined therapeutic outcomes that improve a patient’s quality of life while minimizing patient risk With every therapy there must be a risk, it could be known or unknown These risks are defined as drug misadventures, which includes both adverse drug reactions (ADRs) & medication errors

Definitions Medication error Adverse drug event (ADE)
Adverse drug reaction (ADR)

Adverse Drug Events (ADE)
Definitions Adverse Drug Events (ADE) Any injury caused by a medicine or lack of intended medication Adverse drug reactions & overdoses Dose reductions & discontinuations of drug therapy

Adverse Drug Reaction (ADR)
Definitions Adverse Drug Reaction (ADR) Any unexpected, unintended, undesired, or excessive response to a drug, with or without an “injury” Harm directly caused by the drug at normal doses, during normal use

Definitions Medication Error (ME) Any preventable event that has the potential to lead to inappropriate medication use or patient harm during prescribing, transcribing, dispensing, administering, adherence, or monitoring a drug Medication errors that are stopped before harm can occur are sometimes called “near misses” or more formally, a potential adverse drug event

The Relationship Among ME, ADEs, & ADRs
Medication Errors ADEs ADRs Nebecker et al. Ann Intern Med 2004;140: , J Gen Med 10: ,1995.

What Is The Evidence That Patient Safety Is A Problem?

Evidence That ME is A Problem
Medications harm at least 1.5 million people per year 44,000 to 98,000 hospitalized Americans die each year from medical error Errors cause more death each year than breast cancer, motor vehicle accidents & AIDS Institute of Medicine. Preventing medication errors: quality chasm series, 2006

Evidence That ME is A Problem
The financial burden from these medical errors that is estimated to be in a range of $30 billion to $130 billion annually Up to 28% of these events are thought to be preventable White TJ et al, Pharmacoeconomic. 1999, Classen DC et al, JAMA. 1997

Medication Error Deaths Increasing
ME is A Problem Medication Error Deaths Increasing Deaths from Medication Errors 1983 1998 Phillips DP. Annu Rev Public Health. 2002;23:

Types & Classification of Medication Errors

Types & Classification of ME
NCC MERP index for categorizing medication errors Medication use process Three major areas for medication error: Prescribing Dispensing Administration

NCC MERP Index for Categorizing Errors

Medication Safety & Medication Errors Part II PHCL 311
Hadeel Al-Kofide MS.c

Topics to be covered last lecture
Introduction The evidence that medication error is a problem Definitions The relationship between medication error, ADE & ADE Classifications & types of medication error Reasons for medication errors How to prevent medication error

Topics to be covered today
Focusing on error prevention Identifying medication error How to approach error (Person Vs. System) Methods used to minimize or reduce medication errors Establishing a culture of safety (Building a safer healthcare system ) Medication error reporting system

The Medication Use System
High-Level Portrayal of a Medication Use System Selection & Procuring Establish formulary Prescribing Assess patient; determine need for drug therapy; select & order drug Preparing & Dispensing Purchase & store drug; review & confirm order; distribute to patient location Administering Review dispensed drug order; assess patient & administer Monitoring Assess patient response to drug; report reactions & errors Clinician & administrators All practitioners, plus patient &/or family Physician/ prescriber Pharmacist Nurse/other health professionals Joint Commission. 1998

Major Areas for Medication Error
Medication errors can be broadly classified as Prescribing Dispensing Drug administering errors

Major Areas for Medication Error
39% 38% 12% 11% Medication Errors Reporting Program US

Types of ME Prescribing Errors It is an incorrect drug selection for a patient. Such errors can include the dose, strength, route, quantity, indication, or prescribing contraindicated drug This definition can be further expanded to include failure to comply with legal requirements for prescription writing Williams DJ. 2007, Lesar et al. JAMA. 1997

Prescribing Errors Contributing factors: Illegible handwriting
Types of ME Prescribing Errors Contributing factors: Illegible handwriting Inaccurate medication history taking Confusion with the drug name Inappropriate use of decimal points Use of abbreviations (e.g. AZT has led to confusion between Zidovudine & Azathioprine) Use of verbal order Williams DJ. 2007

Prescribing Errors….. Examples
Name That Drug… Lipitor 10mg PO QD Supposed to be: Lipitor 10mg PO 1 QD Read as: Zyrtec 10mg Filled Rx: Zyrtec 10mg

Name That Drug… 6 unties of regular insulin now Supposed to be: 6 units of regular insulin now Read as: 60 units Filled Rx: 60 units

Name That Drug… Tegretol 300mg BID Filled Rx: Tegretol 1300mg

Name That Drug… Cardura 2mg PO HS & Avandia 4mg PO QAM Filled Rx: Coumadin 2mg PO HS & Coumadin 4mg PO QAM Patient received 6mg of Coumadin PLUS no treatment for hypertension & diabetes

Prescribing Errors…..Examples
Sometimes the technology itself is the problem… Supposed to be: Monopril 40mg - 1 tab PO QD Read as: Monopril10mg Monopril 40mg Filled Rx: Monopril 10mg

Dispensing Errors It is an error that occurs at any stage during the dispensing process from the receipt of a prescription in the pharmacy through to the supply of a dispensed product to the patient Studies have estimated that dispensing errors occur at a rate of % These errors include the selection of the wrong strength/product. This occurs primarily when ≥ 2 drugs have a similar appearance or similar name (look-a-like/sound-a-like errors)

Dispensing Errors…..Examples

Rx AXERT (almotriptan) 6.25 mg 1-2 tablets at once, & repeat in 2 hours if needed up to 25 mg/day Dispensed ANTIVERT (meclizine)

Rx Keppra (anticonvulsant) 500 mg every 12hours Dispensed Kaletra (antiviral)

Administration Errors
Defined as a discrepancy between the drug therapy received by the patient & the drug therapy intended by the prescriber Drug administration is associated with one of the highest risk areas in nursing practice

Drug administration errors largely involve errors of omission where administration is omitted due to a variety of factors e.g. wrong patient, lack of stock Other types of drug administration errors include wrong administration technique, administration of expired drugs & wrong preparation administered

Contributing factors: Failure to check the patient’s identity prior to administration Storage of similar preparations in similar areas Noise, interruptions while undertaking a drug round, & poor lighting Errors More than one tablet for a single dose Calculation is required to determine the correct dose Williams DJ. 2007

Administration Errors…..Examples
A patient had an epidural line for pain management & a peripheral IV line containing insulin The nurse caring for the patient was busy & asked a second nurse to retrieve the next scheduled epidural infusion bag The second nurse delivered a new bag of insulin to the patient’s bedside Without checking the label, the primary nurse hung the insulin infusion to the epidural line

Reasons For Medication Errors
Ambiguous strength designated on labels or in packaging Drug product nomenclature (look-alike or sound-alike names, use of lettered or numbered prefixes & suffixes in drug name) Equipment failure or malfunction Illegible writing Improper transcription & inaccurate dosage calculation Inadequately trained personnel Inappropriate abbreviations Labeling errors Excessive workload Lapses in individual performance Medication unavailable

Focusing on Error Prevention

Can We Do Anything About These Errors?
Step One See the problem

Can We Do Anything About These Errors?
Step Two Identify The Risk & Manage It

Identifying Medication Error

How Can We Identify The Risk?
High alert medication Error prone notations Look-a-like & sound-a-like medications

High Alert Medications
What are high alert medications? How can we reduce the error associated with high alert medications?

"Top 10" Medications Involved in Drug Errors
High Alert Medications "Top 10" Medications Involved in Drug Errors Agent % of Drug Errors Associated with Acute Hospital Care Insulin 4% of all medication errors in 2005 Morphine 2.3% Potassium Chloride 2.2% Albuterol 1.8% Heparin 1.7% United States Pharmacopeia.2007

"Top 10" Medications Involved in Drug Errors
High Alert Medications "Top 10" Medications Involved in Drug Errors Agent % of Drug Errors Associated with Acute Hospital Care Vancomycin 1.6% Cefazolin Acetaminophen Warfarin 1.4% Furosemide United States Pharmacopeia.2007

Strategies To Reduce Risk From High-Alert Medications
Limit the access to these medications Standardizing the ordering/preparation & administration Independent double check at dispensing & administrating phase

Error-Prone Notations
Ambiguous medical notations are one of the most common & preventable causes of medication errors Misinterpretation may lead to mistakes that result in patient harm Delay start of therapy due to time spent for clarification

Implement “Do Not Use” List
Error Prone Notations Implement “Do Not Use” List ISMP & FDA recommend that ISMP’s list of error-prone abbreviations be considered whenever medical information is communicated Complete list is located at: ISMP= Institute for Safe Medication Practices, FDA= Food and Drug Administration

Short List of Error-Prone Notations*
Notations should NEVER be used Notation Reason Instead Use U Mistaken for 0, 4, cc Unit IU Mistaken for IV or 10 QD Mistaken for QID Daily QOD Mistaken for QID, QD “every other day” * Comprises “Do Not Use” list required for JCAHO accreditation

Notations should NEVER be used Notation Reason Instead Use Trailing zero (X.0 mg) Decimal point missed “X mg” Naked decimal Point (.X mg) “0.X mg” cc Mistaken for U “mL” MS Can mean Morphine Sulfate or Magnesium Sulfate “Morphine Sulfate” * Comprises “Do Not Use” list required for JCAHO accreditation

Notations should NEVER be used Notation Reason Instead Use > or < Mistaken as opposite of intended “greater than” or “less than” μ Mistaken for mg “mcg” @ Mistaken for 2 “at” / Mistaken for 1 “per” * Comprises “Do Not Use” list required for JCAHO accreditation

Notations should NEVER be used Notation Reason Instead Use + Mistaken for 4 “and” D/C, dc, d/c Misinterpreted as when “discontinued” followed by list of medications “discharge” or “discontinued” * Comprises “Do Not Use” list required for JCAHO accreditation

Error-Prone Notations…..Examples
Intended dose of 4 units Administered 44 units Should be written as “4 units”

Error-Prone Notations…..Examples
Intended dose of “.4 mg” Administered 4mg Should be written as “0.4 mg.”

Strategies To Reduce The Risk From Error Prone Notations
NEVER use notations

Approaches to Reduce Medication Errors

Person-centered approach System centered approach The Swiss cheese model of systems errors

Person-Centered Approach It has been traditional used in analysis of medication errors It looks at medication errors as occurring due to human frailty, including Forgetfulness Poor motivation Carelessness, not paying attention Negligence

System-Centered Approach Errors expected to occur Errors are viewed as the end result & not the cause There is potential for error & recurring errors in every system, & even the best systems fail

System-Centered Approach Solutions are based on the belief that conditions can be changed, rather than focusing on changing humans Barriers & safeguards should be implemented to help prevent errors It is essential to focus on how & why the system failed & not on which individual failed

Methods Used to Minimize or Reduce Medication Errors

Reducing Medication Error
Steps to minimize medication error Prescriber actions Pharmacy (dispensing) actions Nurse (administrator) actions

Steps to Minimize Medication Error
Forcing functions & constraints Automation & computerization Standardization & protocol Checklist & double check system Rules & policies Education/ Information Be more careful, be vigilant Most effective Least effective

Forcing functions & constraints Use pharmacy system that will not fill any order unless allergy information, patient weight & height are entered Use computer order entry with dosage checks Remove dangerous IV drugs (e.g. conc. potassium, hypertonic sodium chloride) from ward stock Limit choices of available drugs in pharmacy Limit dosage strengths & concentration for each drug Mix IVs in the pharmacy

Automation & computerization (Reduce reliance on memory) Use drug-drug interaction checking system Use computerized order entry Use computerized patient information Use bar-coding on drugs, containers, medication records, patient wristbands Automated dispensing on patient care unit

Standardization & protocol No error –prone abbreviations Use generic names rather then brand name Use standard equipment—one kind of pump or syringe Use protocol for complex medication administration e.g. heparin, chemotherapy

Prescriber Action to Reduce ME
Stay current & knowledgeable concerning changes in medication & treatment Utilize pharmacist consultation if available Ensure that drug orders are complete, clear, unambiguous & legible Including patient weight, dosage (mg/kg/dose or/day), frequency & route of administration Avoid use of terminal zero e.g. use 5 rather 5.0 Use a zero to the left of a zero ( use 0.2 rather .2 ) Discuss medication changes with nursing & other staff & families

Pharmacy Action to Reduce ME
Independent double check orders both on calculation & preparation Clarify confusing orders Checking for current patient drug allergy Dispense medication using unit-dose, ready to administration form whenever possible Patient name, generic drug name, patient specific dose on all labels

Nursing Action to Reduce ME
Double check medication calculations Verify drug order & confirm patient identity & weight before administration Have access to drug information on all medications Familiar with the operation of medication administration device

Medication Error Reporting Systems

Medication Error Reporting System
International systems National system Local (in hospital or healthcare setting) system No system

International Systems
The Medication Error Reporting Program operated by United States Pharmacopoeia in cooperation with the ISMP The Joint Commission on Accreditation of Healthcare Organization (JCAHO) sentinel event reporting system The FDA MedWatch program MEDMARX® The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

Pharmacovigilance Data gathering related to the detection, assessment, understanding, and prevention of adverse events Identifying new information about hazards associated with medicines, preventing harm to patients‏ Medical errors are broader category which includes adverse reactions but also other factors (diagnostic errors, equipment failure, nosocomial infections ... )

The Role of Pharmacists in Medication Error Prevention

How Can Pharmacists Reduce ME?
Clinical pharmacist Drug & poison information pharmacist Staff pharmacist Medication safety pharmacist??

Pharmacist on Patient-Care Team
A full-time unit-based clinical pharmacist substantially decreased the rate of serious medication errors in ICU by 66% Studies shows that clinical pharmacy services & increase hospital pharmacy staffing are associated significantly with reduction in medication errors Leape LL et al. JAMA.1999, Kaushal R et al. American Journal of Health-System Pharmacy.2008

Clinical Pharmacy & ME Reduction
Drug histories Drug information services Adverse drug reaction monitoring Drug protocol management Medical rounds participation 51% 18% 13% 38% 29% Bond CA et a. Pharmacotherapy.2002

Always remember “to Err is Human!”

Medication Safety & Medication Errors Part I PHCL 311

Similar presentations

Presentation on theme: "Medication Safety & Medication Errors Part I PHCL 311"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Medication Safety & Medication Errors Part I PHCL 311

Similar presentations

Presentation on theme: "Medication Safety & Medication Errors Part I PHCL 311"— Presentation transcript:

Similar presentations

About project

Feedback