Introduction to medication safety

1. Introduction to medication safety

2. Rationale • medication use has become increasingly complex in recent times • medication error is a major cause of preventable patient harm • as future pharmacist, you will have an important role in making medication use safe

3. Learning objectives • To provide an overview of medication safety • To encourage you to continue to learn and practise ways to • improve the safety of medication use

4. Knowledge requirements • understand the scale of medication error • understand the steps involved in a patient using medication • identify factors that contribute to medication error • learn how to make medication use safer

5. The importance of medication safety • Medication errors are a leading cause of mortality in the United States.* • Dispensing errors account for ~21% of all medication errors. • In addition to causing serious morbidity and mortality, dispensing errors increase the economic burden on society by adding to health care costs. * Kohn LT, Corrigan JM, Donaldson MSIoM (2000). To Err is Human: Building a Safer Health System (Washington D.C.: National Academy Press).

6. Definitions • side-effect: a known effect, other than that primarily intended, relating to the pharmacological properties of a medication • e.g. opiate analgesia often causes nausea • adverse reaction: unexpected harm arising from a justified action where the correct process was followed for the context in which the event occurred • e.g. an unexpected allergic reaction in a patient taking a medication for the first time • error: failure to carry out a planned action as intended or application of an incorrect plan • adverse event: an incident that results in harm to a patient WHO: World alliance for patient safety taxonomy

7. Definitions • an adverse drug event: • may be preventable (usually the result of an error) or • not preventable (usually the result of an adverse drug reaction or side-effect) • a medication error may result in … • an adverse event if a patient is harmed • a near miss if a patient is nearly harmed or • neither harm nor potential for harm • medication errors are preventable

8. Steps in using medication • Ordering or Prescribing • Dispensing • transcribing • Reviewing • administering • Monitoring and documentation Note: these steps may be carried out by health-care workers or the patient; e.g. self-prescribing over-the counter medication and self-administering medication at home

9. Prescribing involves … • choosing an appropriate medication for a given clinical situation taking individual patient factors into account such as allergies • selecting the administration route, dose, time and regimen • communicating details of the plan with: • whoever will administer the medication (written-transcribing and/or verbal) • and the patient • documentation

10. Administration involves … • obtaining the medication in a ready-to-use form; may involve counting, calculating, mixing, labeling or preparing in some way • checking for allergies • giving the right medication to the right patient, in the right dose, via the right route at the right time • documentation

11. The 5 Rs • right drug • right route • right time • right dose • right patient

12. Monitoring involves … • observing the patient to determine if the medication is working, being used appropriately and not harming the patient • documentation

13. How can monitoring go wrong? • lack of monitoring for side-effects • drug not ceased if not working or course complete • drug ceased before course completed • drug levels not measured, or not followed up on • communication failures

14. Dispensing errors • Dispensing errors include any inconsistencies or deviations from the prescription order, such as dispensing the incorrect drug, dose, dosage form, wrong quantity, or inappropriate, incorrect, or inadequate labeling. • Also, confusing or inadequate directions for use, incorrect or inappropriate preparation, packaging, or storage of medication prior to dispensing are considered to be errors

15. How to avoid dispensing errors • Ensure correct entry of the prescription.  • Confirm that the prescription is correct and complete. • Beware of look-alike, soundalike drugs. • Be careful with zeros and abbreviations. • Organize the workplace. • Reduce distraction when possible.  • Focus on reducing stress and balancing heavy workloads.  • Take the time to store drugs properly. • Thoroughly check all prescriptions. • Always provide thorough patient counseling. 

16. Look-a-like and sound-a-like medications • Celebrex (an anti-inflammatory) • Cerebryx (an anticonvulsant) • Celexa (an antidepressant)

17. Ambiguous nomenclature • Tegretol 100mg • S/C • 1.0 mg • .1 mg • Tegreto 1100 mg • S/L • 10 mg • 1 mg

18. Avoiding ambiguous nomenclature • avoid trailing zeros • e.g. write 1 not 1.0 • use leading zeros • e.g. write 0.1 not .1 • know accepted local terminology • write neatly, print if necessary

19. Which patients are most at risk of medication error? • patients on multiple medications • patients with another condition, e.g. renal impairment, pregnancy • patients who cannot communicate well • patients who have more than one doctor • patients who do not take an active role in their own medication use • children and babies (dose calculations required)

20. In what situations are staff most likely to contribute to a medication error? • inexperience • rushing • doing two things at once • interruptions • fatigue, boredom, being on “automatic pilot” leading to failure to check and double-check • lack of checking and double checking habits • poor teamwork and/or communication between colleagues • reluctance to use memory aids

21. Know which medications are high risk and take precautions • narrow therapeutic window • multiple interactions with other medications • potent medications • complex dosage and monitoring schedules • examples: • oral anticoagulants • Insulin • chemotherapeutic agents • neuromuscular blocking agents • aminoglycoside antibiotics • intravenous potassium • emergency medications (potent and used in high pressure situations)

22. Know the medication you prescribe/dispense well • do some homework on every medication you prescribe • suggested framework • pharmacology • Indications • Contraindications • side-effects • special precautions • dose and administration • regimen

23. Use memory aids • textbooks • personal digital assistant • computer programmes, computerized prescribing • protocols • free up your brain for problem solving rather than remembering facts and figures that can be stored elsewhere • looking things up if unsure is a marker of safe practice, not incompetence!

24. Remember the 5 Rs when prescribing, dispensing and administering • Can you remember what they are? • right drug • right dose • right route • right time • right patient

25. Communicate clearly • the 5 Rs • state the obvious • close the loop

26. Develop checking habits • when prescribing a medication • when administering medication: • check for allergies • check the 5 Rs • remember computerized systems still require checking • always check and it will become a habit!

27. Summary • medications can greatly improve health when used wisely and correctly • yet, medication error is common and is causing preventable human suffering and financial cost • remember that using medications to help patients is not a risk-free activity • know your responsibilities and work hard to make medication use safe for your patients