Medication Safety Part 1

1. Medication SafetyPart 1

2. Outline • Medication safety terminology • Relationship between medication errors, adverse drug events & adverse drug reactions • Medication error classification • Factors contributing to medication errors

3. Medication Misadventure • An iatrogenic hazard or incident associated with medications • May be attributable to error (human, or system, or both), immunologic response or idiosyncratic response • Is always unexpected or undesirable to the patient and the health professional • A medication misadventure may or may not cause an injury to a patient

4. Adverse Drug Event (ADE) • An injury form a medicine (or lack of intended medicine)

5. Adverse Drug Reaction (ADR) • Any unexpected, unintended, undesired, or excessive response to a drug that: 1. Requires discontinuing the drug (therapeutic or diagnostic), 2. Requires changing the drug therapy, 3. Requires modifying the dose (except minor dose adjustments), 4. Necessitates admission to a hospital, 5. Prolongs stay in a health care facility, 6. Necessitates supportive treatment, 7. Significantly complicates diagnosis, 8. Negatively affects prognosis, or 9. Results in temporary or permanent harm, disability, or death

6. ADRs • An allergic reaction (animmunologic hypersensitivity, occurring as the result of unusual sensitivity to a drug) and • An idiosyncratic reaction (an abnormal susceptibility to a drug that is peculiar to the individual) are considered ADRs

7. Side Effect • An expected, well-known reaction resulting in little or no change in patient management • The frequency of this effect is predictable and the intensity is dose-related • e.g. drowsiness or dry mouth due to administration of certain antihistamines

8. Medication Error • Any preventable event that has the potential to lead to inappropriate medication use or patient harm while the drug is in the control of the healthcare professional, patient, or consumer

9. Relationship between Medication errors, ADEs, ADRs Medication Misadventure A B ADE E D Medication Error ADR C

10. Relationship between Medication errors, ADEs, ADRs • Medication misadventures (A) include all things that can go wrong in drug use • ADRs (C) are a subset of ADE and are not related to an error (e.g. allergies) • Section (D) is ADEs resulting from a medication error (e.g. reactions resulting from unintentional overdose)

11. Relationship between Medication errors, ADEs, ADRs • ADEs within section (B) but are not part of sections (C) or (D) are side effects (expected and unavoidable) • Section (E) includes medication errors that don’t result in patient harm (e.g. dose administered late but did not result harm in the patient)

12. Medication Use Process

13. Medication Use Process - Cont’d

14. Medication Errors

15. Medication Error Definition • Any preventable event that has the potential to lead to inappropriate medication use or patient harm while the drug is in the control of the healthcare professional, patient, or consumer

16. Medication Errors • Medication errors cause at least one death every day and • injure approximately 1.3 million people annually in the United States

17. Classification A) Type of Event

18. Classification A) Type of Event

19. Classification A) Type of Event

20. Classification A) Type of Event

21. Classification A) Type of Event

22. Classification A) Type of Event

23. Classification B) Step of Medication Use Process Administering Prescribing Monitoring Dispensing Systems

24. Factors That Contribute to Medication Errors • Miscommunication (verbal & telephone orders) • Poor handwriting/ Use of abbreviations • Product confusion (e.g. sound/look-alike) • Inaccurate dosage calculation • Availability of multiple concentrations • Preparation of drug product outside pharmacy • Stress (workload & environment) • Environment (e.g. lighting, noise levels, frequent interruptions)

25. Factors That Contribute to Medication Errors - Cont’d • Inadequate staffing • Student providing care • Shift change • Lack of experienced personnel on duty • New employee (< 6 months) • Equipment failure or malfunction • Inappropriate abbreviations used in prescribing • Labeling errors • Lack of patient education • Reference material (inaccurate, out of date)

26. High-Alert Drugs Definition • Drugs that are involved in the majority of medication errors that resulted in serious injury or death

27. High-Alert Drugs Examples • Insulin • Opiates/Narcotics • Concentrated injectable potassium • Intravenous anticoagulants • Concentrated sodium chloride solutions • Antiarrhythmics • Chemotherapy • Parentral CCBs and BBs • Oral hypoglycemics • Warfarin

28. High-Alert Drugs Risk Reduction Strategies

29. Look-Alike Medications • These refer to names of medications, which due to their spelling, may look similar to other medications’ names • Distribution/administration of these medications may be prone to errors • Also refer to product labeling/packaging Example Prozac ® and Proscar ®

31. Sound-Alike Medication • These refer to names of medications, which due to their pronunciation, may sound similar to other medications’ names • Distribution/administration of these medications may be prone to errors Example • Dianben ® and Diovan® • Furosemide and Famotidine