1. By Ruth Kavita Senior Pharmaceutical Technologist, KNH

2. Introduction Medication error is any preventable event that may cause, or has caused patient harm while the medication is in control of a health care professional (e.g. Doctor, Pharmacist, Nurse) or patient. Medical errors are not defined as intentional acts of wrongdoing Not all medical errors rise to the level of medical malpractice and negligence. 2

3. Stages of medical errors There are different stages in which a medication error can happen: Prescribing of medication Dispensing of medication Administration of medication 3

4. Prescribing stage of medication Potential errors include: Ordering the incorrect dose Ordering the incorrect drug Ordering the wrong interval or schedule Ordering the wrong route of administration Ordering the wrong rate Ordering the wrong dose form (tabs, liquid) Use of abbreviations and decimal points 4

5. Prescribing stage of medication cont’d Handwriting that is illegible Incomplete orders Ordering and not being alert to allergies Ordering without reviewing and being aware of current medications patient is taking resulting in adverse reactions Wrong transcription e.g Lanoxin vs Laroxyl Wrong calculation 5

6. Sound- alike anticancer 6

7. Prevention of errors at prescribing stage Educating the prescriber Educating the nurse Completing a thorough assessment of the patient’s history including allergies and current medications Clarifying orders that are illegible Review by the consultant pharmacist of medication profiles. 7

8. Dispensing phase Potential errors include: Dispensing the wrong drug, wrong dose, wrong quantities Inaccurate directions for use of medications Failure to educate patient on use of medication Incorrect labeling Dispensing an expired medication Dispensing without knowing patient allergies Dispensing to the wrong patient 8

9. Look-alike drug labels 9

10. Similar packaging antihypertensives 10

11. Prevention of errors at dispensing stage Counterchecking dispensed medications Checking the expiration dates on drugs Checking the integrity of the drug Be clear of proper use of the drug Clear concise instructions for medication usage Clarifying all questionable orders Knowing what the drug is used for Know patient allergies 11

12. Administration of medications stage Potential errors include: Omitting medications Not shaking a medication that should be Wrong storage Crushing medications not intended to be crushed Use of inappropriate diluents Administering the wrong medications Incomplete container delivery Adsorption (container / IV sets) 12

13. Storage of different drugs together 13

14. Similar packaging 14

15. Look-alike antibiotics 15

16. Factors that contribute to the occurrence of medical errors Distractions Stress Increased workload Lack of education Failure to follow policy and procedures Poor tracking systems to identify cause and prevention of errors 16

17. 9 “Rights” to effective prevention of medication errors Right patient Right drug Right route Right time Right dose Right documentation Right action Right form Right response 17

18. Case studies- KNH 1. Findings of medication errors in oncology pharmacy - March to December 2010 Figure 1: Type of Errors 18

19. Case studies Cont’d Figure 2: Description of prescribing errors 19

20. 2. Summary of interventions at Pharmacy 8 for the month of February, 2012 20

21. 3. Summary of errors at IP ART Pharmacy between March and April 2014 March…………40 April…………..39 Most errors and omissions were related to Age and Weight 21

22. Way forward Strengthen system for reporting medication errors Comprehensive education and training of all involved staff Different storage areas for important drugs (e.g. concentrated potassium chloride) Use of technology e.g automated dispensing cabinets, more advanced infusion devices, electronic prescribing Increasing manpower 22

23. Thank you! 23