Transcript REVIEW OF MEDICATION ERRORS-KNH

By Ruth Kavita
Senior Pharmaceutical Technologist, KNH
Introduction
• Medication error is any preventable event that may
cause, or has caused patient harm while the
medication is in control of a health care professional
(e.g. Doctor, Pharmacist, Nurse) or patient.
 Medical errors are not defined as intentional acts of
wrongdoing
 Not all medical errors rise to the level of medical
malpractice and negligence.
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Stages of medical errors
There are different stages in which a medication error
can happen:
 Prescribing of medication
 Dispensing of medication
 Administration of medication
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Prescribing stage of medication
Potential errors include:
 Ordering the incorrect dose
 Ordering the incorrect drug
 Ordering the wrong interval or schedule
 Ordering the wrong route of administration
 Ordering the wrong rate
 Ordering the wrong dose form (tabs, liquid)
 Use of abbreviations and decimal points
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Prescribing stage of medication
cont’d
• Handwriting that is illegible
• Incomplete orders
• Ordering and not being alert to allergies
• Ordering without reviewing and being aware of
current medications patient is taking resulting in
adverse reactions
 Wrong transcription e.g Lanoxin vs Laroxyl
 Wrong calculation
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Sound- alike anticancer
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Prevention of errors at prescribing
stage
 Educating the prescriber
 Educating the nurse
 Completing a thorough assessment of the patient’s
history including allergies and current medications
 Clarifying orders that are illegible
 Review by the consultant pharmacist of medication
profiles.
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Dispensing phase
Potential errors include:
 Dispensing the wrong drug, wrong dose, wrong
quantities
 Inaccurate directions for use of medications
 Failure to educate patient on use of medication
 Incorrect labeling
 Dispensing an expired medication
 Dispensing without knowing patient allergies
 Dispensing to the wrong patient
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Look-alike drug labels
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Similar packaging antihypertensives
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Prevention of errors at dispensing
stage
• Counterchecking dispensed medications
• Checking the expiration dates on drugs
• Checking the integrity of the drug
• Be clear of proper use of the drug
• Clear concise instructions for medication usage
• Clarifying all questionable orders
• Knowing what the drug is used for
• Know patient allergies
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Administration of medications
stage
Potential errors include:
 Omitting medications
 Not shaking a medication that should be
 Wrong storage
 Crushing medications not intended to be crushed
 Use of inappropriate diluents
 Administering the wrong medications
 Incomplete container delivery
 Adsorption (container / IV sets)
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Storage of different drugs
together
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Similar packaging
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Look-alike antibiotics
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Factors that contribute to the
occurrence of medical errors
 Distractions
 Stress
 Increased workload
 Lack of education
 Failure to follow policy and procedures
 Poor tracking systems to identify cause and prevention
of errors
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9 “Rights” to effective prevention of
medication errors
 Right patient
 Right drug
 Right route
 Right time
 Right dose
 Right documentation
 Right action
 Right form
 Right response
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Case studies- KNH
1. Findings of medication errors in oncology pharmacy March to December 2010
Figure 1: Type of Errors
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Case studies Cont’d
Figure 2: Description of prescribing errors
60
51
48
50
No Dose
BSA calculation
Wrong route
Number
40
Interaction
28
30
25
19 19
20
11
10
5
5
Contraindication
Required med not
prescribed
Wrong Medicine /
Regimen
Premeds missing
Lower doses
6
2
Higher doses
0
1
Frequency / duration
Type of e rror
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2. Summary of interventions at Pharmacy 8
for the month of February, 2012
INTERVENTION ON
FREQUENCY OF DOSING
HIGH
17
LOW
09
%
45.61
DOSE
DRUG INTERACTIONS
DURATION OF TREATMENT
ALLERGIES
CONTRAINDICATIONS
COMBINATIONS
TOTAL
NO.
OF
INTERVENTIONS
04
11
02
03
10
57
01
8.77
19.29
3.50
5.26
17.54
100
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3. Summary of errors at IP ART Pharmacy
between March and April 2014
 March…………40
 April…………..39
 Most errors and omissions were related to Age and
Weight
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Way forward
 Strengthen system for reporting medication errors
 Comprehensive education and training of all involved
staff
 Different storage areas for important drugs (e.g.
concentrated potassium chloride)
 Use of technology e.g automated dispensing cabinets,
more advanced infusion devices, electronic prescribing
 Increasing manpower
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Thank you!
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