Medication Errors /PHARMACY

7/27/2019 Medication Errors /PHARMACY

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MEDICATION

ERRORS



Medication errors definition

• The American society of health systems

pharmacists (ASHP) defined medication

errors includes,

Prescribing Dispensing Medications

Administration patient Compliance errors



• What is the medication error?

• is an event connected with the use of

medication

• That event should be prevented through

effective control systems• {A consumers has 0 error expectation}



Where do errors occur?

1. Prescribing

2. Transcribing (writing down)3. Dispensing

4. Administering

5. patient non compliance errors



1. Medication Prescribing Process

Components: Communication

• Written Prescription Orders

• Medication Ordering Systems

• Electronic Order Transmission

• Dosage Calculations

• Verbal Orders



Written Medication Orders: illegible

(Unreadable) Handwriting

• Represents common cause of prescribing errors

• Delays medication administration

• Interrupts workflow

• Prevalent and expensive claim in malpractice cases



• Written Medication Orders: illegible (Unreadable)Handwriting (continued)

• The written medication order is the first place in which aprescribing error may occur

• Due to poor handwriting, written orders require extratime to interpret

• Worse, illegible handwriting on medication orders is acommon cause of prescribing errors, and patient injuryand death have resulted



Written Medication Orders: illegible (Unreadable)

Handwriting (continued

• There may be legal result to illegible

handwriting.

• In order to clarify these illegible ordersthe health care practitioner’s work flowis typically interrupted.



In order to prevent prescribing errors,

written medication orders should

• be readable;

• include complete information;

• consider patient-specific information;

• avoid abbreviations;

• express weight, volumes, and units usingthe metric system;

•avoid decimals;

• deal cautiously with drug names;

• and include the medication's purpose.



Written Medication Orders: physicians have

to avoid decimals – Use 500 mg for 0.5 g

– Use 125 mcg for 0.125 mg

• Never leave a decimal point “naked”

– Haldol .5 mg Haldol 0.5 mg

• Never use a terminal zero – Colchicine 1 mg not 1.0 mg

• Space between name and dose

• Inderal40 mg Inderal 40 mg

• Pharmacist should equally be careful when dealing with decimals

calculation



A line on colchicines made the dose look more like 10 mg

The Synthroid order looks more like 1 mg than 0.1 mg.



Lined prescription forms

• After receiving an overdose for several weeks, the patient wasadmitted to the hospital for hyperthyroidism and wt loss.

• The medication error was recognized during a medical history whenthe patient showed a physician the prescription container label.

• At the time, tablets of 0.5 mg were marketed so the error was madeusing only two tablets per dose.

• Synthroid =LEVOTHYROXINE, is a thyroid hormone



Written Medication Orders:

Drug Names that look- or sound-alike

• They increase the risk for medication errors

• When they have overlapping dosage ranges the

potential for errors may be even greater



Written Medication Orders:Drug Names that look- or

sound-alike

• “Confirmation bias”

•

is a common cause of name mix-ups .• For example, a health care provider in a poorly written

medication order may see the name of a drug with

which he/she is most familiar and overlook any

evidence to the contrary



Written Medication Orders: Drug

Names• Some pharmacy computer systems have software to alert

pharmacists about problem name pairs and some of thepharmacy benefit managers are beginning to alertpharmacists during the prescription adjudication process

• For example, a note reminds the pharmacist entering anorder for Norvasc®(a mlodipine) treats high blood pressureand the chest pain of angina) that it often looks likeNavane®.(THIOTHIXENE ) is used to treat schizophrenia)

• The pharmacist can then confirm the order if necessary.



Written Medication Orders: Drug Names

• Another potential medication prescribing error, relatedto drug name, may occur when a suffix is added to analready marketed drug name.

• Sometimes suffixes are erroneously left off ofprescription orders.

• For example, if a prescription for Depakote ER isaccidentally written as Depakote, the patient wouldreceive the wrong dosage form.

• Depakote ER ,epilepsy migrane



Look-alike & Sound-alike Drug Names

• This list No1 of look-alike and/or sound-alike drug

name pairs have been reported to the USP

Medication Error Reporting Program.

• May not sound alike when they are read or look

alike in print; however, when handwritten or

communicated verbally they can be confused

• A more complete list of these drug name pairs canbe obtained at

www.usp.org/reporting/review/qr66.pdf.



List No1:Look-alike and or Sound-alike Drug Names

.2001,6accessed on February.pdf 66www.usp.org/reporting/review/qr USP Quality Review.

Accutane®ccupril®

Lorazepam Alprazolam

Cardura®Cardene®

Fosamax®Flomax®

Lomotil®Lamisil® Neoral®Nizoral®

Prilosec®Plendil® Zyrtec®Zantac®

http://www.usp.org/reporting/review/qr66.pdf








are two examples of look-alike drug

names Examples above

1. Flouroquinolone( antibiotic) Tequin

(gatefloxacin) or Tegretol (carbamazepine), a

drug used in epilepsy?

2. The anticoagulant Coumadin (warfarin) or

Avandia (rosiglitazone), for treating diabetes

• Imagine the harm to a patient who received

the wrong medication in either of these cases



remind prescribers to include the

purpose of the medication

• Some prescription forms remind prescribers to includethe purpose of the medication.

• this allows the pharmacist an additional method tocheck their interpretation of the order

• Since few look-alike and sound-alike drug pairs have

similar therapeutic indications, these types of errorsmay be avoided by stating the purpose for which themedication is prescribed



Resistance to including the purpose of the

medication on a prescription

• sometimes arises from:

•the fear of violating patient confidentiality,

• the extra time required, and

• the concern that insurers will deny payment for

off-label indications.





• Some physicians use prescription pads with

icons to describe each medication’s purpose

• Use of the icons may overcome some of the

concerns associated with including the

medication's purpose on a prescription.

• A vertical bar displays icons which represent

various therapeutic categories.





• This vertical bar(next slide).

• The prescriber then places a check in front of

the appropriate icon e.g.

• circle the blood pressure cuff for

antihypertensives, the heart for cardiac

medications, etc.

• There are over 30 icons available to satisfy

the needs of different specialties



Insert Figure 3

hen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.



Medication Prescribing Process: Electronic Prescribing

– Computer with 3 Interacting Databases• Drug History

• Drug Information/Guidelines Database

• Patient-Specific Information i.e., age, weight,

allergies, diagnoses, and laboratory data – Avoids

• Illegible Prescriptions

• Improper Terminology

• Ambiguous Orders• Incomplete Information

Schiff GD. JAMA 1998; 279: 1024-9.



Medication Prescribing Process:

Electronic Prescribing

• electronic prescribing tools could minimize

medication errors related to handwriting.

• such devices are not widely used

• could eliminate illegible prescriptions

• could ensure the use of proper terminology

•Could ensure that complete information couldbe avoided





• Computers can maintain accurate, unbiased, and up-to-date drug databases.

• Prescribers can receive on-screen prompts for drug-specific dosage information, with reminders to ensurethat look-alikes and sound-alikes are not confused.

• Vital patient-specific information, such as overdosewarnings, drug interactions, and allergy alerts, can bepresented in the course of prescribing, so that potential

adverse drug events that would otherwise gounrecognized can easily be avoided.





• EP can expedite refill requests, once patients areentered into the system.

• Computers can facilitate data exchange to

enhance teamwork between clinicians andprofessionals who represent other parts of themedication management system, such as;• pharmacists in retail, hospital, and

• online environments;• pharmacy benefit managers (PBMs);

• and health plans.





• Computers updates physicians on changes in

formularies and insurance coverage.

• Computers use can reduce healthcare costs

through time and efficiency savings and by

encouraging prescribers to consider lower-

cost drug options.





• Easy-to-use point-of-care systems,

• some that offer comprehensive applications

in real time, are becoming available from a

number of manufacturers-and at perhaps a

surprisingly low cost of entry.





• Such integrated programs may provide:

• benefits for cost and risk management as well as

for clinical care, and

• they may enhance the prescribing process

beyond addressing penmanship alone.



Medication Prescribing Process: Electronic Prescribing

• For example, hand-held devices can alertpractitioners to potential drug or allergy

interactions via up-to-date databases of medications that are connected withpatient records.

•That kind of functionality should help toexpand rapidly adoption of electronicprescribing among practitioners.





• Of course, computerized medication managementsystems certainly are not the only solution.

• Moreover, clinicians' use of hand-held technology willnot solve the broad spectrum of medication errors,

• for technology is but one part of a larger solution thatincludes such simple and low-tech strategies asseparating look-alike medications in a dispensingcabinet.

• Still, while technology does not offer a perfectsolution,



• ISMP( inistitute of save medication practice)

does believe that technology, if ppropriately

and aggressively used, holds great promisefor :

• researching,

• identifying,• reporting, and

• reducing medication errors.



• In particular, ISMP believes that:

• electronic prescribing-

• with proper systems design, implementation,

and maintenance-

• can contribute significantly to the prevention

•

of • medication errors today.



• In particular, ISMP believes that:

• There is no reason to wait for legislative

activity or task forces to insist that this

capability be utilized as fully as possible.

• Put simply, handwritten prescriptions ought tobe a thing of the past.



Dosage Calculations

• Recognized cause of medication errors

• Use patient-specific information

– height

– weight – age

– body system function

• should be used to calculate dosages whenthe medication is influenced by thosefactors.1

hen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.



Verbal Orders:

Error Prevention

• Avoided when possible

• Pronounce slowly and distinctly

• State numbers like pilots

(i.e., “one-five mg” for 15 mg)

• Spell out difficult drug names

•Specify concentrations

en MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.



Verbal Orders:

Error Prevention

• V.orders should be avoided whenever possible

• When a verbal order is necessary, it should be

spelled out slowly and distinctly

• Numbers should be stated in the way pilots

state them ( i.e., “one-five mg” instead of “fifteen

mg”) Difficult drug names should be spelled out.

For example, an order for “NPH insulin 16 units”can easily sound like “NPH insulin 60 units.”



Verbal Orders:

Error Prevention

• “Read back” is an important way to prevent errorsdue to misinterpretation of verbal orders.

• In the example above, had the listener repeatedthe dose as “six-zero units” the error would have

been readily recognized.• Physicians who telephone prescriptions should ask

the pharmacist (or nurse) to repeat the medicationorder, spelling the drug name that was heard.

• Was that “Cerebyx for epileptic seizures.• ” or Celebrex(NSAID)?”

http://en.wikipedia.org/wiki/Seizure

http://en.wikipedia.org/wiki/Seizure



Verbal Orders:

Error Prevention

• various strengths and concentrations of specific

liquid medications are available,

• concentrations or strengths should be specified

for orders

• Avoid giving the dose in number of teaspoonful,

tablets, ampoules or vials.



Verbal Orders:

Error Prevention

• E.g. Tylenol infant drops (available as 80 mg

acetaminophen/ 0.8 mL); were confused with

children’s acetaminophen elixir (160 mg/5 mL).



Pharmacist and medication errors

• Pharmacists are responsible for the accurate

dispensing of medications

• Pharmacists have a long-standing interest in

improving medication safety and have studied

the ways and means to reduce medication

errors.

• Yet they can make errors

44




• Dispensing errors• generally fall into 2 broad categories:

1. errors of commission:

• (ie, dispensing the wrong medication)

• errors of omission are errors in judgment

2. errors of omission:

• failure to counsel patients,

• ignoring a significant drug interaction or allergy history,

• or improper patient specific dosing

• Errors of commission usually are mechanical in nature




Dispensing errors

• Dispensing is an integral part of the quality use of

the medicines& together with the patient

counseling form the core professional activities of

a pharmacist.

• These activities allow the safe and efficient

provision to the general public of what would

normally be dangerous or restricted drugs.




Dispensing errors

• dispensing errors may be extensive, including

• patient morbidity and mortality,

• increased health expenditure due to

hospitalization and treatment, and

• loss of credibility and professional standing

for the pharmacist along with

• the risk of court case and financial loss.

Di i ( i d)



Dispensing errors(continued)

• Dispensing errors generally refers to errors in:the dispensing process e.g.

1. wrong drug or dose strength

2. incorrectly labeled directions

3. drug dispensed to wrong patient that are notdetected and corrected prior to the patientleaving the pharmacy and which may be to suboptional outcome of treatment for the patients.

4. incorrect admixtures of medications within thepharmacy

M i i k f i d i h h



Main risk factors associated with the

Dispensing errors

• prescription overload

• lighting levels

• Noise

• interruptions and distractions

• Also the major parts of the dispensing errors

were related to wrong drug or wrong strength

Most Common Causes of



Most Common Causes of Errors Cited By Pharmacists

• Too many telephone calls• Overload/unusually busy day

• Too many customers

• Lack of concentration

• No one available to double-check

• Staff shortage

• Similar drug names

• No time to counsel

• Illegible prescription

• Misinterpreted prescription



Dispensing error

• Administration Errors: • An error originating during the process directly associated with

medication administration at the nursing unit

• Monitoring errors:

• Failure to review a prescribed regimen for appropriateness, or

failure to use appropriate clinical or laboratory data for adequateassessment of resident response to prescribed therapy.

• Potential errors:

• A mistake in prescribing, dispensing or planned medicationadministration that is detected and corrected through intervention

before actual medication administration.• Compliance errors:

• Inappropriate resident behavior regarding adherence to aprescribed medication administration.



Pharmacy Actions to Decrease Medication Errors

• Pharmacists are to be available to prescribers and nurses andcommitted to participate in drug therapy development andmonitoring

• No guessing or assumption for a confusing medication order

• Review an original copy of the written medication orderbefore dispensing a medication, except in emergencysituations.

• Prepare drugs in a clean and orderly work area with aminimum of interruption

• Dispense medication in a timely fashion using a unit-dose,ready-to-administer form whenever possible.

• Provide counsel to patients or caregivers about their drugs



Actions to Decrease Medication Errors

• Actions to Decrease Medication

Errors are available in literature fornurses physicians, prescribers and

patients and also further details

Ph A ti t D M di ti E



Pharmacy Actions to Decrease Medication Errors,

further details

• Lock up/remove drugs that may cause catastrophic medication errors

• Develop and implement careful procedures for drug storage

• Use reminders, such as labels and computer notes, to prevent mistakes with

"look-alike" and "sound-alike" drug names

• Keep the original prescription order, the label, and the medication containertogether throughout the dispensing process

• Perform a final check on the contents of prescription containers

• Compare the contents of the medication container with information on theprescription label



Role Of Pharmacists In Medication Errors Reduction

• Medication errors can occur at any time

• The reports of medication errors and interventions

should be evaluated and incorporated in to

Continuous Quality Improvement program (CQI)

• The pharmacist must assume responsibility for

developing and implementing a plan for the

prevention of medication errors through detectionand evaluation



Pharmacist and Assessment

• Pharmacist needs to:• Examine and evaluate the cause of medication errors and

analysis of aggregated data to determine trends, significances,frequency and outcomes

• Evaluate the medication use process in collaboration withother healthcare professionals

• Establish a process for identifying and tracking medicationerrors

• categories of medication errors, e.g. prescribing, dispensing,

administration, monitoring, compliance errors, etc.• develop a medication error reporting and evaluate form

(a simplified documentation system)



Pharmacist and prevention

• Increase awareness of medication error througheducating about the importance of all medicationerrors

•Establish systems for detecting medication errorin the facility and pharmacy, e.g. observation,random sampling, and medication storage surveyetc.

• Involve healthcare practitioners, patients andcare givers in the medication error detection andreporting process



Pharmacist and Reporting

• Donot focus on the punitive aspects to encourage

medication error reporting and focus on the

improvement of process and systems.

• Respect the confidentiality of patient, facility and

personnel involved in the medication errors



Pharmacist and Reporting

• Pharmacists should lead efforts to examine

where errors arise in the drug use system.

• A quality assurance program that regularly

examines all aspects of the drug use system

and also produce information required to

identify problems and allow for appropriate

changes is necessary



Partners collaboration

• Pharmacists, pharmacy technicians, and other

health care professionals involved in the

medication use process must work together to

develop a systems approach to medication

error reduction



Remember once more

• The interruptions to the pharmacist should be

reduced as they break up the attention on the

prescription at hand.

• Distraction by non – professional activities waspotentially dangerous and this should not occur.

• Interruptions can be reduced by providing a

comfortable waiting area and providingpharmacist support personnel’s (Technician or

Assistant).



Remember once more

• The difficulty that community pharmacies had inseparating commercial and patient care interestmay also be cited as a major reasons forincomplete professionalism.

• The overall medium response to reduce theMedication errors like, having mechanism forchecking dispensing procedures, systematic

dispensing workflow, checking originalprescriptions, keeping knowledge of the drugs upto date etc.

The importance of quality assurance



The importance of quality assurance

procedures

• It reduces the occurrence

• if well designed it will lead to identifying the errorsand implement strategy to correct them

• Standards in the dispensing process must setappropriately high towarss a zero error



Detection of Medication Error • To make safer systems we must be able to learn from

previous errors and

• detection is the first key step

•We are made vigilant and our knowledge of risks is raisedand our performance may be improved by visiting the:

• reports,

• alerts and

• recommendations made available on the web,

issued by national and federal healthcare systems, regulatoryagencies, and non-profit-making organizations [ (FDA, EMEA),(USP-MEDMARX), (UK –NHS) etc



Detection of Medication Error

• The approaches used to detect errors are likely to

be different in research and routine care, given the

available resources

• to prevent medication errors and reduce the risksof harm, detection tools are needed

• systems must be able to analyze errors and identify

opportunities for quality improvement and systemchanges

The major methods for detecting



The major methods for detecting

adverse events are

1. chart review

2. computerized monitoring

3. incident reporting and

4. searching claims data



for medication errorsDetection

methods to be discussed1. Chart review

2. Claims data

3. Incident reporting (sentinel events)

• Voluntary reporting

• Administrative data examination

4. Computer monitoring

• Direct care observation

• Patient monitoring

Medication Errors /PHARMACY

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