PROF. GOVIND MOHAN Department of Pharmacology GLA UNIVERSITY Institute of Pharmacy, Mathura

1. MEDICATION ERROR? PROF. GOVIND MOHAN Department of Pharmacology GLA UNIVERSITY Institute of Pharmacy, Mathura

2. WHY MEDICATION ERRORS? • HUMAN BEINGS WILL ALWAYS MAKE ERRORS • ERRORS ARE COMMON IN MEDICINE, KILLING TENS OF THOUSANDS • WE BEGIN TO KNOW SOMETHING ABOUT THE EPIDEMIOLOGY OF ERROR, BUT WE NEED TO KNOW MUCH MORE • NAMING, BLAMING AND SHAMING HAVE NO REMEDIAL VALUE. Continued….

3. WHY MEDICATION ERRORS? • WE NEED TO DESIGN HEALTH CARE SYSTEMS THAT PUT SAFETY FIRST (FIRST, DO NO HARM) • WE KNOW A LOT ABOUT HOW TO DO THAT • IT’S A LONG, NEVER ENDING JOB

4. PATIENT DRUG INTAKE DRUG INDUSTRY DOCTOR PRESCRI-PTION CAUSING AGENTS OF MEDICATION ERROR PHARMACIST DISPENSING NURSE ADM. OF DRUG Continued….

5. CAUSING AGENTS DRUG INDUSTRY: • MISTAKES CAN HAPPEN IN THE MANUFACTURE OF DRUGS (eg. WRONG EXCIPIENTS). • PROPER STORAGE PROCEDURES NOT OBSERVED, MAKING THE DRUGS USELESS eg. USING EXPIRED TETRACYCLINE HAS BEEN KNOWN TO CAUSE FANCONI’S SYNDROME. • FAILURE TO PROVIDE CORRECT PRESCRIBING INFORMATION: 10mg/Kg 6 HOURLY, WHICH IS THE Continued….

6. DRUG INDUSTRY WRONG INTERPRETATION, OR 10mg/Kg/Day TO BE DIVIDED EVERY 6 HOURS, WHICH IS CORRECT. • FAILURE TO DO POST-MARKETING SURVEILLANCE BY MANUFACTURERS, AND IF DONE, NOT COMMUNICATING THESE DATA IN THEIR PACKAGE INSERT. • MISLEADING HEALTH AND TREATMENT CLAIMS BY INDUSTRY. Continued….

7. DOCTOR PRESCRIPTION • WRONG ROUTE OF ADMINISTRATION . • PRESCRIBING THE WRONG FORMULATION (eg. USING SLOW RELEASE DRUGS INADVERTENTLY WHEN THE DOCTOR MEANT ORDINARY TABLETS). • INCORRECT DURATION OF TREATMENT . • PRESCRIBING WRONGLY FOR A GIVEN INDIVIDUAL eg. ALLERGY etc. Continue….

8. DOCTOR PRESCRIPTION • PRESCRIBING THE WRONG DRUG. • WRITING ILLEGIBLY. • CONFUSING NAME OF ONE DRUG WITH ANOTHER. • PRESCRIBING OR WRITING THE WRONG DOSE. Continued….

9. DOCTOR PRESCRIPTION • WRONG IDENTITY OF THE PATIENT. • FAILING TO ACCOUNT FOR PRE-EXISTING DISEASE/ CONCURRENT THERAPY. • PRESCRIBING WITH INADEQUATE OR INCORRECT INSTRUCTIONS. • PRESCRIBING WITHOUT INFORMED CONSENT OF THE PATIENT • OFF-LABEL USE OF DRUGS.

10. PHARMACISTS DISPENSING • DISPENSING ERRORS viz. GIVING 250 mg/5ml PARACETAMOL INSTEAD OF THE PRESCRIBED 125 mg/5m UNINTENTIONALLY. • MISINTERPRETING DOCTOR’S PRESCRIPTION AND FAILURE TO CONFIRM WITH THE DOCTOR. • FAILURE TO PROVIDE ADVICE TO PATIENTS eg. NO EXPIRY DATE ON STRIPS, INFORMATION LEAFLETS ARE NOT PROVIDED.

11. NURSES ADMINISTRATION OF DRUG • ERRORS IN TAKING AND GIVING MEDICINES. • WRONG DRUG. • CORRECT DRUG, INCORRECT DOSE/DILUTION/ FORMULATION. • ENTRAINING AIR PARTICLES OR OTHER CONTAMINANTS WITH THE DRUG SPECIALLY IN PARENTERAL ADMINISTRATION. Continued….

12. NURSES ADMINISTRATION OF DRUGS • ERROR IN ADMINISTRATION (INTERCHANGING IV, IM, INTRATHECAL, ORAL, SUBLINGUAL ROUTE). • GIVING A DRUG OUTSIDE OR AGAINST CURRENTLY ACCEPTED PRACTICE (OFF-LABEL USAGE). • WRONG ROUTE, WRONG SITE, WRONG RATE AND WRONG PATIENT.

13. WHICH PATIENTS ARE MOST AT RISK? • THOSE UNDERGOING CARDIOTHORACIC SURGERY, VASCULAR SURGERY, OR NEUROSURGERY • THOSE WITH COMPLEX CONDITIONS • THOSE IN THE EMERGENCY ROOM • THOSE LOOKED AFTER BY INEXPERIENCED DOCTORS • OLDER PATIENTS

14. PATIENT DRUG INTAKE • MISUNDERSTADING MEDICATION INSTRUCTIONS. • POOR PATIENT COMPLIANCE, NOT COMPLETING DOSAGE REGIMEN. • DRUG PAROXYSM- WHEN A PATIENT TAKES A MEDICINE BUT LATER BECOMES CONFUSED WHETHER HE ACTUALLY TOOK IT AND TAKES A SECOND DOSE ERRONEOUSLY- NOT RESTRICTED TO GERIATRIC PATIENTS.

15. HOW CAN MINIMISE THE ERRORS? • IF IT IS POSSIBLE TO WRITE THE DOSE AS A WHOLE NUMBER, DO SO. • IF IT IS IMPOSSIBLE OR MORE CONFUSING TO WRITE THE DOSE AS A WHOLE NUMBER, ENSURE THAT A ZERO PRECEDES THE DECIMAL POINT. PLACE THE DECIMAL POINT PROPERLY. • COMMUNICATE CLEARLY. MOBILE PHONES AND SHORT MESSAGE SENDING (TEXTING) CAN LEAD TO ERRORS. Continued….

16. DOCTORS, NURSES, AND PHARMACISTS, WHEN TRANSMITTING ORDERS ON PHONE/MOBILES , CLEAR PRONUNCIATION OF MEDICAL TERMS AND LISTENING CAREFULLY CAN PREVENT MISTAKES OF SIMILAR SOUNDING DRUG HOW CAN MINIMISE THE ERRORS? Continued….

17. HOW CAN MINIMISE THE ERRORS? • WRITE A PRESCRIPTION CLEARLY AND GIVE INSTRUCTION TO PATIENTS OR THEIR RESPONSIBLE COMPANIONS. THERE WAS A CASE OF AN OBESE DIABETIC PATIENT BEING MANAGED WITH ORAL HYPOGLYCEMIC MEDICINE AND INSTRUCTED TO DECREASE WEIGHT IN A VAGUE MANNER. THE PATIENT DECIDED TO SKIP BREAKFAST AS A ‘DIET CONTROL’ MEASURE BUT CONTINUE TAKING HER MEDICINE, LEADING TO SYMPTOMATIC HYPOGLYCEMIA. • CONTINUED Continued….

18. HOW CAN MINIMISE THE ERRORS? • PRESCRIPTION SHOULD HAVE ALL THE ESSENTIAL INFORMATION LIKE DOSAGE STRENGTH, THE NUMBER OF TABLETS, FREQUENCY OF ADMINISTRATION, ROUTE. • BE CONSERVATIVE. PRESCRIBE ONLY WHEN ABSOLUTELY NEEDED. DON’T SATISFY THE WHIMS OF PATIENTS WHO REQUEST ANTIBIOTICS TO TREAT COMMON COLDS. • KNOW YOUR PATIENT’S CONDITIONS WELL BEFORE PRESCRIBING DRUGS. Continued….

19. HOW CAN MINIMISE THE ERRORS? • PRESCRIBE A MEDICINE WHICH YOU ARE THOROUGHLY FAMILIAR WITH (ADVERSE EFFECTS, CONTRAINDICATION, WARNINGS) P-drug concept. DON’T BE TEMPTED TO PRESCRIBE NEW DRUGS PROMOTED AGGRESSIVELY BY DRUG COMPANIES. • AVOID OVER –PRESCRIBING; THIS IS COSTLY & CAN LEAD TO ACCIDENTAL OVERDOSE. Continued….

20. HOW CAN MINIMISE THE ERRORS? • AVOID POLYPHARMACY. ALTHOUGH NOT ALL POLYPHARMACY IS BAD WHEN THESE MEDICINES ARE ACTUALLY NEEDED, BE ATTENTIVE TO THOSE WITH POTENTIAL FOR HARMFUL INTERACTIONS & BE WARRY OF DRUG-DRUG INTERACTIONS. • SPEND TIME TO EDUCATE A PATIENT ABOUT THE DRUG-WHEN TO TAKE IT, WHEN TO STOP, WHAT TO EXPECT (eg. CHANGE IN COLOUR OF URINE?) HOW TO RECOGNIZE DRUG INTERACTIONS & STORAGE. Continued….

21. HOW CAN MINIMISE THE ERRORS? • SOME DRUGS WHEN TAKE FOR A LONG TIME, SHOULD NOT BE STOPPED ABRUPTLY (E.G. ANTICONVULSANTS, STEROIDS, SEDATIVE HYPNOTICS). • SOME DRUGS WHEN TAKEN FOR LONG-TERM, MAY LEAD TO DRUG DEPENDENCE AND ABUSE. Continued….

22. HOW CAN MINIMISE THE ERRORS? • PAY SERIOUS ATTENTION TO THE PATIENT’S HISTORY, SUCH AS RECORDS OF HYPERSENSITIVITY, ALLERGIES, IDIOSYNCRASIES OR MEDICAL CONDITIONS THAT ARE CONSIDERED CONTRAINDICATIONS TO DRUG.

23. PRACTICAL TIPS….. • D/C- AS USED IN HOSPITALS CAN MEAN DISCHARGE, DISCONTINUE OR DILATATION AND CURETTAGE. • AU VS OU- BECAUSE OF SPELLING ERRORS, CAN CONFUSE BOTH EARS WITH BOTH EYES. • DPT VS dpt- A COCKTAIL DRUG PREPARATION USED IN HOSPITALS KNOWN AS DEMEROL, PHENERGAN AND THORAZINE CAN BE CONFUSED WITH PEDIATRIC VACCINES CALLED DIPHTHERIA, PERTUSSIS, & TETANUS. Continued….

24. PRACTICAL TIPS….. • HCL vs KCL- AGAIN H and K CAN BE MISREAD & INSTEAD OF HYDROCHLORIC ACID, POTASSIUM CHLORIDE IS USED. • Per os vs left eye-os IS SOMETIMES USED IN HOSPITAL CHARTS TO MEAN OPENING, BY MOUTH OR BY TUBE AND CAN ALSO MEAN THE LEFT EYE. • QD vs QID- ONCE A DAY MAY BE CONFUSED WITH FOUR TIME A DAY. • QN vs EVERY HOUR qh- AS LETTER N and H CAN BE MISREAD, EVERY NIGHT IS MISTAKEN AS EVERY HOUR, Continued….

25. PRACTICAL TIPS….. • QOD vs DAILY- THIS IS PARTICULARLY CONFUSING WHEN DOCTORS MAKE ABBREVIATIONS MISINTERPRETING EVERY OTHER DAY, OR ONCE EVERY DAY. • SC vs SL- C FOR CUTANEOUS CAN BE MISTAKEN AS L FOR SUBLINGUAL. • IU vs IV- INTERNATIONAL UNITS AS OPPOSED TO INTRAVENOUS, FOR INSTANCE, INSULIN EXPRESSED IN UNITS TO BE GIVEN SUBCUTANEOUSLY MAY BE ERRONEOUSLY GIVEN AS INTRAVENOUS BOLUS.

26. CONCLUSION • MEDICATION ERRORS CAN HAPPEN UNINTENTIONALLY. HEALTH PROFESSIONALS SHOULS BE VIGILANT ON FINDING WAYS TO PREVENT THESE ERRORS. ONE WAY IS TO STRENGTHEN EDUCATION AND SURVEILLANCE SYSTEMS WITHIN THE ADR REPORTING CONTEXT. THE ROLE OF PHARMACOVIGILANCE CENTERS CAN BE EXPANDED TO ADDRESS PROBLEMS THAT OCCUR IN THE CLINICAL Continued….

27. CONCLUSION SETTING. EVERY HEALTH PROFESSIONAL INVOLVE IN THE THERAPEUTIC CHAIN SHOULD ALWAYS QUESTION THE DECISIONS MADE BY THE ONES BEFORE THEM (NURSES AND PHARMACISTS QUESTION THE PRESCRIBER ON MEDICATIONS AS PRESCRIBED ETC.) • IT WOULD BE SERIOUS TO HEAR THIS FROM OUR PATIENT: “DOCTOR, I PREFER THE DISEASE TO THE SIDE EFFECTS OF THE MEDICINES YOU GAVE.”

28. THANKS