Medication Safety Medication Errors Part I PHCL 311

1. Medication Safety & Medication ErrorsPart IPHCL 311 Hadeel Al-Kofide MS.c

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. The Relationship Among ME, ADEs, & ADRs

9. What Is The Evidence That Patient Safety Is A Problem?

10. 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

11. 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

12. Medication Error Deaths Increasing

13. Types & Classification of Medication Errors

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

15. NCC MERP Index for Categorizing Errors

16. Medication Safety & Medication ErrorsPart IIPHCL 311 Hadeel Al-Kofide MS.c

17. 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

18. 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

19. The Medication Use System

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

21. Major Areas for Medication Error

22. 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

23. 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

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

25. Prescribing Errors�.. Examples Name That Drug� Supposed to be: 6 units of regular insulin now Read as: 60 units Supposed to be: 6 units of regular insulin now Read as: 60 units

26. Prescribing Errors�.. Examples Name That Drug�

27. Prescribing Errors�.. Examples Name That Drug�

28. Prescribing Errors�..Examples Supposed to be: Monopril 40mg - 1 tab PO QD Read as: Monopril10mgSupposed to be: Monopril 40mg - 1 tab PO QD Read as: Monopril10mg

29. 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 1-24% 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)

30. Dispensing Errors�..Examples

31. Dispensing Errors�..Examples

32. Dispensing Errors�..Examples

33. Dispensing Errors�..Examples

34. Dispensing Errors�..Examples

35. 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

36. Administration Errors 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

37. Administration Errors 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

38. Administration Errors�..Examples A patient had an epidural line for pain management & a peripheral IV line containing insulin

39. 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

40. Focusing on Error Prevention

41. Can We Do Anything About These Errors?

42. Can We Do Anything About These Errors?

43. Identifying Medication Error

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

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

46. "Top 10" Medications Involved in Drug Errors

47. "Top 10" Medications Involved in Drug Errors

48. 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

49. 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

50. Implement �Do Not Use� List ISMP & FDA recommend that ISMP�s list of error-prone abbreviations be considered whenever medical information is communicated

51. Short List of Error-Prone Notations*

52. Short List of Error-Prone Notations*

53. Short List of Error-Prone Notations*

54. Short List of Error-Prone Notations*

55. Error-Prone Notations�..Examples

56. Error-Prone Notations�..Examples

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

58. Approaches to Reduce Medication Errors

59. Approaches to Reduce Medication Errors Person-centered approach System centered approach The Swiss cheese model of systems errors

60. Approaches to Reduce Medication 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

61. Approaches to Reduce Medication Errors 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

62. Approaches to Reduce Medication Errors 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

63. Methods Used to Minimize or Reduce Medication Errors

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

65. Steps to Minimize Medication Error

66. Steps to Minimize Medication Error 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

67. Steps to Minimize Medication Error 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

68. Steps to Minimize Medication Error 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

69. 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

70. 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

71. 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

72. Medication Error Reporting Systems

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

74. 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)

75. 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 ... )

76. The Role of Pharmacists in Medication Error Prevention

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

78. 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

79. Clinical Pharmacy & ME Reduction Drug histories Drug information services Adverse drug reaction monitoring Drug protocol management Medical rounds participation