Avoiding Drug Errors

1. Avoiding Drug Errors Paul W. Jones, DO, MHA, FAOCA

2. World Health Organization �To err is human; To cover up is unforgivable; To fail to learn is inexcusable.�

3. Errors not Just in Healthcare 2 upside down labels and a blank label Can also have double openers Top and bottom Or no openers This one gets most complaints!

4. Post Office Errors Perforations are misplaced or missing Can significantly raise the value of the stamp for collectors

5. U.S. Mint Coin Errors Error coins are rare Most found before release Can be valuable Errors include: Double dies Off-center strikes Clipped

6. Ford Pinto Design Error According to Ford's estimates, the unsafe tanks would cause 180 burn deaths, 180 serious burn injuries, and 2,100 burned vehicles each year Essentially, Ford argued before the government that it would be cheaper just to let their customers burn!

7. $11 Fix too Expensive for Ford

8. Calif. Appellate Court DecisionOn Ford�s appeal of a Verdict on Pinto Flaws

9. Columbia Shuttle DisasterFeb 1, 2003

10. Columbia Design Errors

11. To err is human: Building a safer health system* Report suggested that 98,000 patients died as a result of medical errors every year in the US Two in 100 admissions involve a preventable adverse drug event Increasing inpatient costs by 2 billon dollars Finding: computerized physician order entry can cut drug errors by 50 per cent

12. Error Some errors can occur even when individuals have the required knowledge to perform a task correctly Examples: Forgetting change when using a vending machine Forgetting the original document after making photocopies, and Forgetting to turn the oxygen after completing a case These errors can occur when you are distracted by something else

13. Police say a western New York tow truck driver was texting on one cell phone while talking on another when he slammed into a car and crashed into a swimming pool. The truck then crashed through a fence and sideswiped a house before rolling into an in-ground pool. Police say the 68-year-old woman driving the car suffered head injuries Sparks was charged with reckless driving, talking on a cell phone and following too closely.

14. O.R. Distractions Boom boxes Cell phones Texting Irate surgeon�s Multi-tasking Excessive conversations Computers � Goggling Paying on-line bills Balancing checkbook Reading (magazines, newspaper) Knitting Writing letters Others

15. DEDICATION We are looking for someone willing to work anyplace � at anytime

16. What is an Error? The concrete meaning of the Latin word error is "wandering" or "straying". An act, assertion, or belief that unintentionally deviates from what is correct, right, or true. The condition of having incorrect or false knowledge. The act or an instance of deviating from an accepted code of behavior. A mistake.

18. Even Surgeons Have Error Reduction Techniques

19. Eye Drop Look-a-likes When similar, highly stylized corporate logos, fonts, package sizes, and color combinations are factored in Drugs look alike Mistakes easily made

20. National Health ServicesDrug Errors Study Most errors caused no harm, but 2,000 led to moderate or severe harm and 36 deaths The medication errors figures cover incidents in England and Wales the 12 months to July, 2006 �Only way NHS will achieve real improvements for patients is by being frank about the problems and challenges that it faces� Study showed: 80% caused no harm, 15% low harm and 5% moderate or severe harm.

21. �Braking� News Someone obviously errored when this train went through a French train terminal

22. Confirmation BiasThe Reason for many Drug Errors The tendency to search for or interpret new information in a way that confirms one�s preconceptions and to irrationally avoid information that contradicts prior beliefs If you are looking for ephedrine When you pick up epinephrine, you confirmed that you got what you wanted (even though you picked up the wrong drug)

23. Murphy�s Law of Research "Enough research will tend to support your theory." �It must be one of these pills� ?Confirmation Bias?

24. Chernobyl Disaster Large scale decontamination operation scraping off topsoil after disaster - radio-operated bulldozers performed poorly in areas of high radioactivity On 26 April 1986 01:23:45 a.m. reactor number four exploded This was a nuclear reactor accident in Ukraine , then part of the Soviet Union Worst nuclear disaster in history resulting in a severe release of radioactivity Four hundred times more fallout was released than had been by at Hiroshima

25. Chernobyl Nuclear Disaster The operators of the plant held too much faith in the reactor A catastrophe was simply inconceivable They had no fear disabling the safety features of the reactor For unknown reasons, the operator committed a critical error and inserted the control rods too far - leading to the disaster

26. Aftermath of Errors The city of Pripyat had to be abandoned Chernobyl is seen in the distance Trains help evaluate residents Many died from radiation poisoning

27. Alexander PopeEnglish writer and Poet, 1688-1744 �To err is human, to forgive is divine� �A little learning is a dangerous thing; Drink deep, or taste not the Pierian spring�* �Fools rush in where angels fear to tread�

28. Tolstoy SyndromeRussian Writer, Leo Tolstoy, 1897 � The most difficult subjects can be explained to the most slow-witted man if he has not formed any idea of them already; but the simplest thing cannot be made clear to the most intelligent man if he is firmly persuaded that he knows already � what is laid before him.�

29. Napoleon�s Tactical Error The Battle of Berezina took place Nov. 26-29, 1812 as Napoleon�s Army was retreating after the invasion of Russia The French Army was left without a means of escape After heavy French losses, the Russians were victorious Now �Berezina� has been used in French as a synonym for �disaster�

30. Napoleon�s Error One error and its catastrophic results: Napoleon�s retreat from Moscow, as painted by Adolph Northen in the 19th century

31. Vigilance Knowing that you are capable of making errors is important Ask yourself why am I giving this medication? Is it a �high risk� drug? Be extra careful when in stressful situation READ the label

32. Supervision Double check your student/resident�s selection of drugs Call you when case status deteriorates Instruct the learner to call you if they are not familiar with a drug Double check with learner about how �emergency drugs� prepared Check patient allergies/sensitivities

33. Continuous Epidural Pump bag tubing should have no injection ports or sites No one except anesthesia providers to make connections Many drugs could be disastrous if injected intrathecally or in the epidural space

34. Ketorolac Error Resident gave I.V. ketorolac to an asthma patient that was �aspirin� sensitive Immediately, severe bronchospasm developed Difficult to treat - had significant desaturation before treatment gradually became effective

35. Heparin Medication Errors Similar looking drugs Heparin: 10 units/mL 10,000 units/mL Three infants died after given the higher dose FDA and Baxter notified healthcare professionals of this potential fatal error

36. Full-Strength Heparin ErrorsPharmacist meant to dilute for flushing Nurses intended to use the blood-thinner to flush IV tubes to prevent clot formation Hospital pharmacists mixed Heparin 100 times too strong Since Heparin is a widely used to flush IV tubes it accounts for many medication errors in hospitals. Approximately 250 such errors involving children under 18 months.

37. Twins of Dennis Quaid given Massive Heparin Overdose Heparin overdoses killed three infants in 2006 and nearly killed the newborn twins of actor Dennis Quaid The story received a great deal of media coverage Quaid has since become an activist for the prevention of medication errors Has testified before Congress about medical errors

38. Bar-Code Medication Administration Systems Errors Prevented by A nurse reported that hydralazine had been stocked in automated dispensing location designated for hydrochlorothiazide. The error was detected by the product�s bar code. Lexapro 10 mg was retrieved for Lexapro 20 mg. The error was detected when the product�s label was scanned before releasing the product for patient use.

39. Bar Code Medicine AdministrationErrors Caused by or Associated with BCMA Technology Staff discovered metoclopramide 10 mg vials bar coded as norcuron 10 mg. A pharmacy department dispensed ketorolac 30 mg syringes to the patient care unit in a zipped-lock bag with a bar code that scanned as heparin 5,000 units.

40. Bar Code Medicine Administration Barcode system still has many �bugs� to work out before ready for �primetime� One more step for anesthesia when time is often critical Might have a place in the future of anesthesia care

41. The Institute of Medicine (IOM) has estimated that each year medication errors injure at least 1.5 million Americans and cost the health system more than $3.5 billion. Drug errors feature prominently in every large-scale study of iatrogenic injury conducted. Fatigue leads to mistakes � often caught by safety-net of nurses Performance degradation

42. Sleep DeprivationCausing Medical Errors To reduce medical errors, the public thinks of disciplining an individual physician The Inst. of Medicine (IOM) report pointed out, what is needed is a systems approach and systems thinking to reduce unintended medical errors and increase patient safety. We need to move away from a culture of name, blame, and shame, said Dr. Clancy (Dir. Of Agency for Healthcare Research and Quality) so that physicians can report medical errors without fear �The only thing worse than screwing up is not learning from it, she noted�

43. Sleep DeprivationCausing Medical Errors To reduce medical errors, the public thinks of disciplining an individual physician The Inst. of Medicine (IOM) report pointed out, what is needed is a systems approach and systems thinking to reduce unintended medical errors and increase patient safety. We need to move away from a culture of name, blame, and shame, said Dr. Clancy (Dir. Of Agency for Healthcare Research and Quality) so that physicians can report medical errors without fear �The only thing worse than screwing up is not learning from it, she noted�

44. Wrong Route can be Fatal An elderly patient recovering from an acute MI was hypokalemic Potassium phosphate was ordered for electrolyte replacement via the intravenous (IV) route Was given as an IV push rather than by infusion Patient arrested immediately - with failed resuscitation

46. Factors Contributing to Drug Errors Distractions 53% ? Workload � 21% Inexper. Staff � 18% Insuf. Staff � 11% Shift change � 7% Temp. Staff � 4% Emergency Situation � 3% Poor Lighting � 0.6% Code Situation � 0.3%

47. Actions taken when Error Occurs Informed one making error - 66% Informed other involved - 19% Education/training - 15% None taken� 14% Improve communications - 12% Inform patient � 3% Change policy/procedure - 1%

48. iPhone Distractions(Blackberries, etc.) *One of the biggest distractions at work is the internet itself �distractions are endless Facebook and twitter only add to the pull People who figure out how to keep web browsing and work separate are going to be the successes in the future They will be productive while their coworkers will have little to show

49. Wrong Administration Technique Examples of Errors Crushing sustained release capsules Aspirating liquid center of capsule and giving I.V. push Failure to flush between meds resulting in precipitation Incorrect IV pump programming and tubing

50. Remifentenil Errors Comes as a powder as 1 (or 2 mg) base 1mg = 1000 mcg (�g) Bolus of 0.5 � 1.0 �g Maint. of 10-20 �g/kg/hr Errors often occur with dilution method (esp. with students/residents) Often prepared over-concentrated - with overdose resulting

52. 100,000 Medical Errors Each Year Common problems include: adverse drug events improper transfusions surgical injuries and wrong-site surgery restraint-related injuries or death falls, burns, pressure ulcers mistaken patient identities High error rates with serious consequences are most likely to occur in intensive care units operating rooms emergency departments

53. 100,000 Medical Errors Each Year *Medical errors can be defined as the failure of a planned to be completed as intended or the use of a wrong plan to achieve an aim. This does not mean only drug errors It related to many types of error that result in potential patient harm

54. 2008 Top 10 Sentinel Events* Wrong site surgery -116 Suicide -102 Delay in Treatment -82 Foreign body left -71 Patient Fall - 60 Op/Post-op Complic. - 63 Medication Error - 46 Assault/Rape/homicide -41 Perinatal death/loss of function - 32 Medical Equip. related - 23 *A sentinel event is defined by The Joint Commission (JCAHO) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a person or persons, not related to the natural course of the patient's illness.

55. Would you Still Fly if�? there were 650 airplane crashes in the U.S. each year with 150 passengers aboard each aircraft Yet, that is equal to the 98,000 deaths due to medical error each year in the U.S.

56. "To err is human�but, don�t get too relaxed� This should not be an excuse to throw your hands up and do nothing

57. Production Pressure in Anesthesia Anesthesia production pressures are defined as: "overt or covert forces or incentives on personnel to make production rather than safety their highest priority."

58. Fatigue Anesthesia providers that are fatigued from working long hours put patients at risk according to research on medication errors

59. Worked Himself to Death Shelly F____ Sleep deprivation � more errors and less compassion Went from hospital to hospital � only changing scrubs Would never refuse work Averaged � 3-4 hrs. sleep/day Fell asleep and patient arrested and died A few weeks later, Shelly fatally shot himself

60. Dr. William S. Halsted Kept marathon hours Had became addicted to cocaine and morphine This period between fighting cocaine addiction and beginning Johns Hopkins marks an abrupt personality change for Halsted from bold and vivacious extrovert to diffident, anti-social introvert. His addition to morphine was revealed in a book by William Osler: The Inner History of Johns Hopkins Hospital.

61. Systems Errors In a national survey 99 self-reported errors by Registered Nurses likelihood of a medication error increased by three times when the nurse worked more than 12.5 hours providing direct patient care. Among nurses working more than 12.5 hours, the reported errors, 58 percent of actual errors and 56 percent of near misses were associated with medication administration.

62. Systems Errors A review of incident reports found that the major contributing factors to errors were inexperienced staff, followed by insufficient staffing, agency/temporary staffing, lack of access to patient information, emergency situation, poor lighting, patient transfers, floating staff, no 24-hour pharmacy, and code situations.44 Certain aspects of shift work can also impact medication safety, as shown in a review of research conducted in the 1980s and early 1990s that indicated that there was a difference in the number of errors by shift, but no difference in the number of hours worked (8 versus 12 hours). However, there were more errors with nurses working rotating shifts.3

63. Systems Errors A review of incident reports found that the major contributing factors to errors were: inexperienced staff, insufficient staffing, agency/temporary staffing lack of access to patient information emergency situation, poor lighting, patient transfers floating staff, no 24-hour pharmacy, and code situations

64. a review of two studies in the literature found that medication errors did not necessarily decrease with two nurses administering medications (e.g., double-checking).

65. Human Factors Related to Errors These factors include characteristics of individual providers (e.g., training, fatigue levels), the nature of the clinical work (e.g., need for attention to detail, time pressures), equipment and technology interfaces (e.g., confusing or straight-forward to operate), the design of the physical environment (e.g., designing rooms to reduce spread of infection and patient falls), and even macro-level factors external to the institution (e.g., evidence base for safe practices, public awareness of patient safety concerns).103 There were 10 studies that assessed the 22 Medication Administration Safety association of human factors with MAEs. Four major themes emerged in the review: fatigue, cognitive abilities, experience, and skills.

66. Neurosurgery Case 40 y.o. patient undergoing craniotomy for subarachnoid bleeding Review of chart revealed that nimodipine (Nimotop) was due � 30 mg P.O. � given to prevent vasospasm Called pharmacy and checked with tech Drew up 30 mg from capsule with liquid center Gave I.V. push followed by 30 ml N/S flush Heart stopped immediately Non-resuscitatable

67. FDA Data Summary The FDA has received reports of medication administration errors in which nimodipine was given intravenously or parenterally, rather than orally. In addition to a fatal case reported in 2005, there has been a history of these errors. Two cases were reported in 1995. Another case, which resulted in death, was reported in 1996.�� Additional non-fatal cases were reported in 1999, and in 2002 (two cases). After the 1996 case, the manufacturer, Bayer, included a bolded statement in the labeling, warning against incorrect administration.�� Because cases are still occurring, FDA has asked Bayer to add a boxed warning to the nimodipine labeling to describe the life-threatening risk of parenteral administration. Additionally, FDA has requested that Bayer develop an oral solution of nimodipine for use in patients who cannot swallow a capsule.��� Nimodipine is a calcium-channel blocker, which lowers blood pressure; when the drug is administered intravenously instead of orally, the effect can be much stronger, leading to cardiovascular collapse and possibly to death.

68. Nimotop Black-box Warning DO NOT ADMINISTER NIMOTOP INTRAVENOUSLY OR BY OTHER PARENTERAL ROUTES. DEATHS AND SERIOUS, LIFE THREATENING ADVERSE EVENTS HAVE OCCURRED WHEN THE CONTENTS OF NIMOTOP CAPSULES HAVE BEEN INJECTED PARENTERALLY (See WARNINGS and DOSAGE AND ADMINISTRATION). Bioavailability: Orally � 13%; I.V. � 100% Therefore: 8 times more available with I.V.!!

69. FDA Recommendations Healthcare providers who prescribe, dispense or administer Nimodipine should administer nimodipine capsules orally only. For patients unable to swallow a capsule, use an oral syringe to extract the gel inside the capsule. The syringe should be labeled �for oral use only.� The nimodipine gel should be administered through the patient�s naso-gastric tube or G-tube, followed by 30 ml normal saline solution (0.9%). Ensure that nimodipine is never administered intravenously, or by any parenteral route.

70. NMBA�s Happened a number of years ago with a SRNA Discussed plan and CRNA talking with surgeon at scrub sink While looking through O.R. window, CRNA notices patient displaying �jerking, uncoordinated movements� SRNA had given pancuronium 7 mg I.V. push prior to induction Patient quickly induced with no apparent recall

71. NMBA�s 20 y.o. patient for inquinal hernia repair Succinylcholine infusion connected to I.V. line via rubber port Patient started fasciculating Succ drip had been turned on while patient awake Patient quickly induced Fortunately, no recall elicited

72. Drug Swap Prior to open-heart induction One provider gave what was thought to be Solu-Medrol (actually fentanyl) as an I.V. bolus Patient become non-responsive Was immediately intubated and ventilated No deterioration of vital signs Procedure done with no adverse outcome Both drugs clearly labeled in 50 ml syringes

73. OB Patient with Fetal Distress 28 y.o. parturient with late-decelerations and bradycardia Prepared with an emergency C-section Anesthetist gives 2 ml Pitocin (20 units) I.V. push Sudden tetanic contractions with further deterioration of fetal heart tones Rushed emergency C-section with poor Apgar scores and need for resuscitation with guarded prognosis of newborn Lawsuit pursued

74. System Drug Errors Look-a-like Drug packaging is a setup for errors Should check three times before preparing drug � but with human nature as it is, sooner or later an error will occur Alert pharmacy of look-a-like drugs to avoid use in the same cart � get from another supplier if necessary

77. Look-a-likes Drugs!

78. Mix 3 gtts of Epinephrine What are gtts anyway? cc�s? ml�s?, drops? Mix 3 drops of epinephrine into 10 ml N/S What size drops? What is the final dose? Good way to get into trouble Always insist on knowing the exact concentration Pre-mixed saves potential disaster of overdose Have the nurse show you the drugs and how it is mixed � that is your right and responsibility to know every drug given during anesthesia

79. Case Report � Epinephrine Error Circulating nurse gave surgeon local infiltration mixture with 3 mg of 1:1000 Epinephrine Surgeon injected the cervix with the solution BP went up to 280/150 Did not awake following anesthesia Sustained severe brain damage

80. Epinephrine Consider not using the 1:1,000 at all Consider asking the OR nursing leadership to write a policy related to use of vasopressors in local anesthetics Consider using pre-prepared solutions only, e.g. 1% lidocaine with 1:100,000 epinephrine

81. Pre-mixed is Safest Reduces the possibility of excessive concentrations (and total dose) of epinephrine Still need to watch for too much total volume and total dose, especially with halogenated agents

82. Drug Mix-up #1

83. Drug Mix-up #2

84. Details are Critical Anesthesia is highly responsible work All patients have concerned families and loved-ones We need to give careful consideration to our anesthesia plan and all aspects of management We need to study problems that have occurred and try to avoid repeating history

85. Gaining Experience Experience is what you get when you expect something else

86. Epinephrine to Control Bleeding Bilateral breast augmentation procedure in plastic surgeon�s office O.R. Following development of pockets for implants, two adrenalin-soaked lap pads placed in each pocket Received 4 mg of epinephrine almost immediately Patient arrested and 911 called � rushed to hospital Intra-aortic balloon pump inserted to augment cardiac output Patient survived with some heart damage Need to verify exactly how epinephrine solution prepared

87. Innovar vs. Isuprel Error committed a number of years ago Innovar (fentanyl and droperidol combination) came in 5 ml ampoule with blue painted label on the glass Isuprel packaged as a 5 ml ampoule with blue painted label on the glass SRNA gave 26 y.o. patient 2 ml of Isuprel (undiluted) Tachycardia to 220 beats per minute

88. Mivacron vs. Mazicon VA hospital Mazican ordered as an infusion Mivacron (mivacurium) given inadvertantly Three patients died of asphyxia Mazicon renamed Romazicon (Roche)

89. NMBA and Reversal Mix-ups Happens not infrequently in pediatric hospitals Several syringes of muscle relaxants and several syringes of reversal drugs mixed at beginning of day Mislabeled or mis-administered so that more NMBA given when reversal is desired

90. Phenylnephrine (Neosynephrine) Gyn procedure in 32 y.o. patient Surgeon asked for local with neosynephrine for infiltration of cervix to control bleeding BP went up to 250/130 Discovered that neo nose drops had been mixed with local Vasodilators used to lower BP with no apparent long-term adverse effects

91. Gaining Experience Experience is what you get when you expect something else

92. Succinylcholine Drips 1 gram of powered-Anectine mixed in 500 ml Has been over-infused many times Leads to a Phase II block � so that the PNS findings appear to look like that produced by a non-depolarizing NMBA Due to speeding up drip to paralyze quickly and then forgetting to turn it down OB patients are more sensitive to SCH due to decreased pseudocholinesterase levels

93. Pharmacy Drug Mix-up Pt. had slurred speech, disorientation, memory loss, had neurological consult) 75 y.o. Morris Ganaden, retired engineer thought he was having a stroke Pharmacy gave him Seroquel (quetiapine) - a potent anti-psychotic - instead of Synthroid Both yellow tablets of different size

94. Medication Errors Wrong drug, incorrect dose or improper use -- harm at least 1.5 million people every year* Confusion caused by drugs with similar names accounts for up to 25 % of the reported errors

95. Common Drug Mix-Ups Zantac (H-2 blocker) ? Zyrtec (antihistamine) Flomax (BPH) ? Volmax (for asthma) Prozac (antidepressant) ? Prilosec (proton pump inhib.) Keletra (for AIDS) ? Keppra (anti-seizure) Taxotere (chemo agent) ? Taxol (different chemo) Lamictal (antiepileptic) ? Lamisil (antifungal) Clinoril (for arthritis) ? Clozaril (for schizophrenia) Enoxaparin (anticoagulant) ? Enoxacin (antibacterial)

97. Branding Strategy One of the biggest problems in naming a drug is one of pure phonics Too many of the roughly 11,000 prescription brand drug products sound alike Sometimes they differ only by a few letters Used to look only at �branding� Now need to pick a name to avoid confusion with other drugs 3.5 billion prescriptions each year in U.S. Every $1 spent in advertising returns $4 in sales

98. Brand InstituteMiami, Florida The function of this company is to come up with brand names for drugs and other products The idea is to give the drug the appropriate identity without confusion with existing drug names They research existing names and trademarks This is big business Then the FDA has to give final approval

99. Mivacron � Mazicon Errors The brand name of flumazenil (Mazicon�) was changed in 1993 to Romazicon� The brand name of flumazenil was changed to prevent confusion with mivacurium (Mivacron) flumazenil is a benzodiazepine antagonist Mivacurium is a neuromuscular blocking agent (discontinued now)

100. Error involving NMBAsVancomycin vs. Vecononium Vancomycin 1.5 g IV was ordered Pharmacist misread the faxed copy of the order and entered vecuronium into the computer A tech prepared the 1.5 g dose using 15 vials of vecuronium Fortunately, the tech affixed a vivid alert sticker stating: �Neuromuscular blocking, patient must be intubated� The nurse noticed, notified the pharmacy and did not give the mega-dose of vecuronium

101. Atracurium Error Atracurium was administered sub-Q - instead of hepatitis B vaccine to seven infants 5 recovered, one had permanent injuries, and 1 died NMBAs had never been stocked in the nursery However, for convenience, an anesthesiologist had placed the vial of atracurium in the unit refrigerator near vaccine vials of similar appearance

102. RMS Titanic Collided with an iceberg on April 14, 1912 1517 people died

103. Several ErrorsMany lessons learned The iceberg could have been sighted � was not Warning message not passed on Ship�s faulty rivets gave under strain A nearby ship turned off its wireless set � �Mayday� messages not received No binoculars on ship Architects miscalculated ship�s buoyancy of sealed compartments