Medication Errors: Overview and Prevention

1. Chapter 11 Medication Errors

2. Overview • Medication error – any preventable event causing or leading to inappropriate medication use or patient harm • Involve health care professionals, patients, or consumers • Occur during manufacturing, prescribing, transcribing, dispensing, and administering medications

3. Occurrence of Medication Errors May happen anywhere Approximately 98,000 Americans die each year as a result of medical errors, with nearly 7,000 of these attributable to actual medication errors (continues)

4. Occurrence of Medication Errors Most errors occur during ordering (39%) and administration (38%), with the rest divided between transcription and pharmacy dispensing

5. Prescribing Errors Most medication errors occur when physicians, nurse practitioners, physician assistants, dentists, and pharmacists order prescriptions Illegible handwriting can cause the wrong drug to be given

6. Dispensing Errors Medication errors during dispensing can be made by pharmacists or pharmacy technicians The pharmacy technician must be skilled in: Generic and trade names of drugs Performing dosage calculations Awareness of sound-alike and look-alike drugs Aseptic technique

7. Administration Errors During administration of medication, errors may occur due to: Misuse of infusion pumps and other parenteral delivery systems Memory lapses Faulty drug identification or dose verification Wrong drug, dose, patient, time, route, technique, or information on the patient chart

8. Rights of Drug Administration

9. The Patient’s Role in Medication Errors They may occur when patients self-administer drugs at home Patients must be informed regarding their: Condition and treatment plan Prognosis Risks and benefits Alternative treatments Complications that may occur Other vital pieces of information

10. Medications of “Highest Alert” According to the Institute for Safe Medication Practices (ISMP), these medications are of “highest alert”: Insulin Narcotics and opiates Potassium chloride injections Heparin Concentrated sodium chloride (>0.9%)

11. Risk Factors for Medication Errors Risk factors include: Fatigue Noise and stress Poor lighting and management Illegible handwriting Inadequate patient monitoring Lack of drug knowledge or patient information Rule violations (continues)

12. Risk Factors for Medication Errors Risk factors include: Problems with herbal remedies and OTC drugs Problems with medications sold over the Internet Illegal drugs

13. Human Factors Human factors related to medication errors include: Lack of attention to details Failure to recognize certain facts Choosing incorrect medications Failing to remember something concerning the medication or patient Making incorrect choices about what actions are to be taken

14. Fatigue Fatigue has many effects that can allow medication errors to occur, including: Slowed reaction times Reduced accuracy Inability to recognize changes in the patient Lapses of attention Impaired communication ability Memory lapses Decreased energy

15. Noise Internal and external noise can interrupt the concentration of health care workers and cause medication errors Types of noise include: Outside construction and traffic noise Interior repair work, conversations, cell phones ringing, and overhead music systems

16. Poor Lighting Adequate, bright lighting has been proven to decrease medication errors by increasing alertness and the ability to read information more accurately Poor lighting may cause labels to be misread

17. Poor Management If pharmacy technicians are not adequately supervised due to staff shortages, they may make errors that will go unchecked by pharmacists or other personnel Other areas of poor management include: Not addressing air-conditioning problems Not addressing unhealthy conditions Not addressing anything that may cause workers to have a lack of focus

18. Stress Stress is often linked to a variety of medication errors Stress causes distraction and lack of focus Stress may be caused by: Personal and family problems Sickness Poverty Conflicts with staff members Dealing with upset or angry patients

19. Illegible Handwriting Illegible handwriting has been documented as the second most prevalent cause of medication errors Methods of counteracting illegible handwriting include: Writing prescriptions more slowly and clearly Dictating or typing prescriptions Reviewing prescriptions for accuracy and clarity Discussing prescriptions with other health care staff members

20. Inadequate Patient Monitoring Health care professionals must monitor patients to ensure safe medication administration and outcomes Vital signs and levels of consciousness can be verified Pain scales are printed charts that patients can view and then respond to Diagnostic tests are also important for patient monitoring

21. Lack of Drug Knowledge Patients who do not understand their medications and the requirements for their use may inadvertently harm themselves Caregivers must likewise be knowledgeable Patients should be encouraged to ask questions about their medications

22. Lack of Patient Information Patient information that is essential in reducing medication errors includes: Age Sex Pregnancy Diagnoses Allergies Height and weight (continues)

23. Lack of Patient Information Patient information that is essential in reducing medication errors includes: Lab test values and diagnostic study results Vital signs Patient identity Ability to pay for prescriptions

24. Rule Violations Health care professionals must follow the rules of their health care practice setting For example, physicians are required to verify allergy history, and pharmacists are required to counsel patients During administration of medications, the “seven rights” of administration must be followed

25. Problems with Herbal Remedies Herbal remedies may interact dangerously with certain medications prescribed by a physician, dispensed by a pharmacist, or administered by a nurse It is vital to ask patients what types of herbal remedies they are taking – they must list all of them

26. Problems with OTC Drugs • Lack of knowledge of drug interactions with prescribed medications

27. Problems with Medications Sold over the Internet Patients often purchase medications via Internet web sites in order to get them more cheaply Often, these web sites originate in other countries that use different formulations They may not be approved by the FDA, and may even be illegal to purchase, as well as being potentially dangerous

28. Illegal Drugs Some patients use illegal drugs, which they often do not report to their physicians The potential for interactions with prescribed drugs is dangerous For example, a sedative prescribed for a patient using heroin or cocaine may severely harm the patient

29. Dangerous Abbreviations andNumerical Terms Medication errors frequently occur when prescribers use abbreviations The “do not use” list includes: U – Write out the word “units” instead IU – Write out “international units” instead QD – Write out the word “daily” instead SC or SQ – Write out the word “sublingual” instead D/C – Write out “discharge” or “discontinue” instead HS – Write out “half strength” or “hour of sleep” instead

30. Leading Zeros and Trailing Zeros Leading zeros should be used before decimal points, as follows: Write “0.2 mg” instead of “.2 mg” Trailing zeros should not be used after decimal points, as follows: Write “2 mg” instead of “2.0 mg”

31. Avoiding Medication Errors Prevention must be the most important priority of health care professionals, and they must educate patients Keep these in mind: Confirm patient’s identity Verify the original prescription, medication calculation, and patient allergy history Communicate concerns to the pharmacist Inquire if the patient has questions for the pharmacist Maintain continuing education

32. Medication Error Reporting The reporting of medication errors and problems with products must be done whenever they occur, even though the reporting process is voluntarily There are two medication error reporting systems: FDA MedWatch Program U.S. Pharmacopeia’s (USP) Medication Error Reporting Program

33. FDA MedWatch Program MedWatch allows reporting of medication errors or product problems by phone, fax, and through the Internet It also provides important and timely clinical information, including: Prescription and OTC drugs Biologics Medical and radiation-emitting devices Special nutritional products

34. USP’s Medication Error Reporting Program This program provides the sharing of medication error experiences through a nationwide network It was designed to recognize circumstances and causes of actual and potential errors Reporting is confidential, and can be anonymous

35. Minimizing Liability Upon detecting an error in dispensing, the pharmacy technician must take all necessary steps to rectify it promptly and notify the pharmacist immediately The pharmacist should inform the patient and prescribing physician immediately

36. Negligence / Malpractice / Penalties Pharmacy laws protect the public by ensuring double-checking of results of the prescribing process and overseeing use of medications Negligence is the failure to do something that a reasonable person might do, or doing something that a reasonable person might not do (continues)

37. Negligence / Malpractice / Penalties Malpractice is negligence performed by a professional Penalties may include restrictions on practice, suspension of practice, fines, revocation of practice, and jail sentences