Reducing Prescribing Errors Case Analysis

1. Reducing Prescribing ErrorsCase Analysis Mohammed AlmoslemPharm.D. Candidate King Saud University & King Fahad Medical City Administration Rotation

2. Introduction • Background about medication errors • The definition of drug related problem, adverse drug reaction, adverse drug event, medication errors, and side effect • Medication use process definitions and its related medication error • Case Scenario • Medication Error Categories • Drug related problem associated errors • Type of medication errors • Performance improvement analysis Outline

3. Medication Safety • One medication error/patient every day • 7000 preventable deaths occurs each year • It costs $17 billion to $37 billionin U.S. • 400,000preventable adverse drug events • Cause more deaths each year than breast cancer, motor vehicle accidents, and AIDS Institute of Medicine, July 2009: Committee on Identifying and Preventing Medication Errors

4. Drug Related Problem Drug Related Problems Adverse Drug Reaction Medication Error Medication Errors Adverse Drug Event Side Effects

5. Medication Use Process Prescribing Dispensing Transcribing Administration Monitoring

6. Case Scenario • Young male came to ER with asthma exacerbation symptoms, he was prescribed: • Salbutamol 100 mcg/puff (VENTOLIN) inhaler 2 puff QID • Fluticasone 250 mcg + Salmeterol 50 mcg/puff accuhaler (SERETIDE) 2 puff daily • Prednisolone 25 mg (PRED FORTE) tablet 2 tablet daily for 4 days • Clomiphene 50 mg (CLOMID) tablet daily for two weeks • One week after, patient complained about receiving "CLOMID" without indication. 

7. What is Clomiphine? • Selective estrogen receptor modulator that increases production of gonadotropins by inhibiting negative feedback on the hypothalamus. • It is used mainly for ovarian stimulation in female infertility due to anovulation.

8. What is Clomiphine? • Approved Indications: • Female infertility due to ovulatory disorder • Female infertility – Polycystic ovary syndrome • Unapproved Indications: • Clomiphine test • Endocrine female infertility – Hyperandrogenemia • Female infertility – Luteal phase defect • Infertility, Idiopathic • In vitro fertilization • Male hypogonadism Micromedex® Healthcare Series [intranet database]. Version 5.1. Greenwood Village, Colo: Thomson Healthcare.

9. Medication Errors Category Category A • The capacity to cause error Category B • An error occurred but did not reach the patient Category C • Reached the patient but didn’t cause patient harm Category D • Reached and require monitoring or intervention Category E • Temporary harm and it require intervention Category F • Require initial or prolonged hospitalization Category G • Permanentharm Category H • Required intervention necessary to sustain life Category I • Death

10. DRP Associated with Error Event involving medication use process Error Outcome Actual or Potential consequence Drug related problem Drug-Related Morbidity Error Negative Outcome Latent Injury No Error No Negative Outcome Potential Injury DRP: Drug Related Problem

11. Type of Medication Errors Sub-therapeutic Over-dosage Correct Drug Adverse Drug Reaction Drug Interaction Error of Commission Improper Drug Selected Errors that cause DRP Incorrect Drug Without Indication Untreated Indication Error of Omission No Drug Failure to Receive

12. Case Scenario Patient came to ER with asthma exacerbation Physician prescribed the medications Pharmacy received the prescription without diagnosis Pharmacy dispensed the medication as prescribed Porter received the medication from the pharmacy

13. Performance Improvement Analysis

14. Reducing Prescribing ErrorsCase Analysis • Find the opportunity: • Reduce prescribing error • 1269 reported errors in prescribing process in 3 months in KFMC • 1111 reported errors in prescribing process in one week* • 700 beds academic medical center in Chicago* • 30.8% of these errors are clinically significant* • 64.4% are likely to be prevented by Computerized Provider Order Entry (CPOE)* • Organize the Team: • Medication safety officer as the leader • The members • ER Physician, Pharmacist, ER nurse *BobbA, Gleason K, Husch M, Feinglass J, Yarnold PR, Noskin GA. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med. 2004;164(7):785-92.

15. Reducing Prescribing ErrorsCase Analysis • Clarify the current process: CPOE • No Clinical Decision Support System • Physician not familiar with CPOE Pharmacist prepared, checked, and dispensed the drug • No diagnosis in the prescription • No communication with the physician • No double check Porter received the medication • No patient counseling

16. Reducing Prescribing ErrorsCase Analysis • Understand the current problem: Not routine Communication Physical Environment Protocols Supervision Staffing Work Environment Task Team Responsibility Heavy Workload PrescribingError Complex Disease Mental Health Language Barrier Physical Health Patient Individual Unhelpful Patient Knowledge & Skills Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 2002;359(9315):1373-8.

17. Reducing Prescribing ErrorsCase Analysis • selectthe desired outcome: • Improve physicians education: • 95% of the ER physicians are aware of using CPOE • Enhance patient counseling: • Less than 5% of medication will be received by porter • Promote pharmacist communication with other healthcare professionals: • 95% of the concerns are revised with the involved healthcare professionals

18. Reducing Prescribing ErrorsCase Analysis • Plan: In-service workshops monthly for the other healthcare professionals • Coordination with the education department • Make a schedule with the topics and the presenters • Make a survey for measure their awareness

19. Reducing Prescribing ErrorsCase Analysis • Plan: Identify the patient using patient name and medical record number • If the medication dispensed to other than the patient • Make a special stamp for the one who received the medication including: • Person name • Signature • Patient contact number

20. Reducing Prescribing ErrorsCase Analysis • Plan: Make a list of the physicians (Resident, Assistant and Consultant) with their contact bleeps • Clarify unclear order • Contact concerned physician for order verification • Contact head of department or designee if ordering physician is not available

21. Reducing Prescribing ErrorsCase Analysis • Do:

22. Reducing Prescribing ErrorsCase Analysis • Check: After 3 months • Compare the total number of reported prescribing errors pre and post intervention • Survey analysis. • Action: • Based on our results, implement the plan in other clinical departments

23. Thank you