Medication Safety

1. Medication Safety • A medication error is a drug error that may or may not reach the patient • It is usually preventable • It is usually unintentional • May or May not cause harm • A medication error that causes death is called a sentinel event by the Joint Commission • When a sentinel event occurs the institution is required to perform a root cause analysis

2. Type of Medication Errors • Prescribing Errors • Involves wrong dose, illegible sigs, wrong frequencies • Incorrectly transcribing verbal orders from MD • Dispensing Errors • Results from mistakes made during dispensing • Physically preparing medications incorrectly (i.e. using 23.4% saline instead 0.9% saline for an IV admixture) • Transcribing sig instructions incorrectly • i.e. Methothexate 12.5 mg tablet TIW as 12.5 mg TID • Error is dosing calculations • Administration Errors • Involves nursing • Incorrect route of administration • Giving KCL 40 meq IVP instead of KCL 40 meq IVPB over 60 minutes (FATAL) • Giving Vincristineintrathecally instead of intravenously (Fatal) • Giving Penicillin G Benzathine IV instead of IM (can be fatal)

3. Causes of Medication Errors • Performance problems • Procedure(s) not followed • Knowledge deficits • Pharmacists/Pharmacy Technicians that may be intoxicated by alcohol or drugs • Social or Family problems • Noise level at work • Distractions

4. Medication Error Reduction Strategies • Joint Commission “Do not use” list • ISMP (Institute for Safe Medication Practices) error prone do not use list • See Lesson 3 “Medical and Pharmacy Terminology” • Also see www.ismp.org/tools/errorproneabbreviations.pdf • ISMP also publishes a list of confused drug names • Example concludes Celebrex-Celexa • List can be found at www.ismp.org/tools/confuseddrugnames.pdf

5. Tall Man Lettering • Tall Man lettering is a strategy implemented by healthcare institutions in the US under the advise of the Joint Commission , FDA and ISMP • Involves drug names that can be confused with one and other, see ISMP confused name’s list • Drugs with similar sounding names or spelling are called LASA drugs-Look Alike Sound Alike drugs • Tall man lettering involves the use of mixed case lettering to distinguish between these drugs • Examples: • buPROPion VS busPIRone • glyBURide VS glipiZIDE • hydrALAZINE VS hydrOXYzine • Tall man strategies involves: labeling of these medications, ADC cabinet display, separating these drugs on pharmacy shelves

6. High Alert Medications • Medications that when used in error can result in serious patient harm including death • ISMP has collected a list of such drugs

7. High Alert Medication Strategies • US hospitals and healthcare institutions have published their own lists that mirrors the ISMP list with some additions. • Strategies include: • Specialized color code labeling for these medications • Segregating the medications in the pharmacy inventory • Restricting access to these drugs in the ADC (non overrideable) • Specialized alerts in the CPOE and the pharmacy systems • Use of standardized preparations of these drugs • i.e. Heparin USP 25,000 units/250 ml D5W

8. Do Not Crush List • ISMP publishes a do not crush list • These drugs should never be crushed • Typically patients that can’t swallow or have feeding tubes, NG tubes and PEG tubes have their oral dose forms crushed and administer in about 30 ml of liquid • Crushing some drugs alters their time course of activity, stability, or exposure potential to pharmacy personnel • Drugs that are long acting • Effexor XR, Cardizem CD, Detrol LA, KDUR, Paxil CR, Seroquel XR • Drugs that are enteric coated • Ecotrin • Depakote • Nexium • Powerful GI irritant • Actonel® • Teratogenic (exposure to female pharmacy personnel) • Isotretinoin • Sublingual Dose Forms • Nitroglycerin

9. How to report med errors and adverse drug events • FDA Medwatch • ISMP MERP database • Institute of Medicine (IOM) • TJC (Joint commission) • USP Medmarx • FDA and CDC VAERS system for vaccines