Transcript medications

Chapter 6
Medication Safety
Learning Objectives
• Understand the extent and effect of medical errors on
patient health and safety
• Describe how and to what degree medication errors
contribute to medical errors
• *List examples of medication errors commonly seen
in practice settings
• Apply a systematic evaluation of opportunities for
medication error to a pharmacy practice model
• Identify the common medication error–reporting
systems available
Medical Errors
• A medical error is any circumstance, action, inaction,
or decision related to healthcare that contributes to an
unintended health result
• Most of what is known about medical errors comes
from information collected in the hospital setting
– hospital data make up only a part of a much larger picture
– most healthcare is administered in the outpatient, officebased, or clinic setting
• Medical errors are difficult to define
– possible causative circumstances are infinite
Medical Errors
• Medical-related lawsuits show the scope of medical
errors in the United States
• One large government studied only medical errors
during hospitalization
– 44,000 to 98,000 people in the U.S. die each year as a
result of medical errors (greater than the risk of death from
accident, diabetes, homicide, or human HIV and AIDS)
– multiple sources for potential medical errors exist
Discussion
What are some examples of medical errors?
Edited by Dr. Ryan Lambert-Bellacov
Discussion
What are some examples of medical errors?
Answer: Lab tests drawn at the wrong time
(inaccurate results), major surgical errors ending
in injury or death
Medication Errors
• A medication error is a medical error in which the
source of error or harm includes a medication
• Like medical errors
– medication errors have no specific definition because
the possible causes can be endless
– information on the effect of medication errors comes
mostly from studies done in the hospital setting
• Medication-related deaths are estimated at about
7,000 each year
Medication Errors
• Fewer studies of medication errors in community
practice exist
– an estimated 1.7% of all prescriptions dispensed in a
community practice setting contain a medication error
(4 of every 250 prescriptions)
• Not all medication errors result in harm to a patient
– 65% of the medication errors detected had a meaningful
effect on the patient’s health
Medication Errors
• Measuring results of medication errors
– lost lives
– disabled patients
– time lost from work or school
• cost to the healthcare system
– billions of dollars
– physician visits
– additional hospitalizations
– emergency room visits
– admissions to long-term care
– continuation of disease
Healthcare Professional’s Responsibility
• Working in healthcare means making a commitment
to “first do no harm”
• The profession of pharmacy exists to safeguard the
health of the public
• Healthcare must focus on treating the patient
– to the best possible outcome
– by the safest possible means
• No “acceptable” level of medication error exists
– effect of a potential medication error on the patient cannot
be predicted
– each step in fulfilling medication orders should be reviewed
with a 100% error-free goal
Healthcare Professional’s Responsibility
The only acceptable level of medication errors
is zero.
Edited by Dr. Ryan Lambert-Bellacov
Healthcare Professional’s Responsibility
• MA’s can identify potential patient sources of
medication error
– careful listening and observation during a patient or medical
staff interaction
– notifying the pharmacist
• MA’s make a significant contribution to patient safety
– constant surveillance for potential sources of medication
error
Tips for Reducing Medication Errors
• Always keep the prescription and the label together
• Know common look-alike and sound-alike drugs
• Keep dangerous or high-alert medications in a
separate storage area
• Always question bad handwriting
• Prescriptions/orders should be correctly spelled with
drug name, strength, appropriate dosing, quantity or
duration of therapy, dose form, and route
• Use the metric system
Tips for Reducing Medication Errors
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Question uncommon abbreviations
Be aware of insulin mistakes
Keep the work area clean and uncluttered
Verify information
Labels should always be compared with the original
prescription by at least two people
Healthcare Professional’s
Responsibility
If information is missing from a medication
order, never assume. Obtain the missing
information from the prescriber.
Edited by Dr. Ryan Lambert-Bellacov
Tips for Reducing Medication Errors:
MA’s
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Use the triple-check system
Regularly review work habits
Verify information with the patient or caregiver
Observe and listen
Keep your work area free of clutter
Edited by Dr. Ryan Lambert-Bellacov
Patient Response
• Most patients have the intended therapeutic
response expected from the medication
• Unique physical and social circumstances make it
impossible to predict which
– medication errors may result in no substantial harm
– may result in death
Physiological Causes of Medication
Errors
• Each patient has a unique response to medication
– genetically unique
– speed at which medications are removed from
body varies
• Even a problem caught and corrected before harm
occurs is still considered a medication error
Social Causes of Medication Errors
• Outpatients can contribute to medication errors
through incorrect administration
• Social causes of error include:
– failure to follow medication therapy instructions because
of cost
– noncompliance
– failure to receive therapy
– misunderstanding instructions (language barriers)
Edited by Dr. Ryan Lambert-Bellacov
Social Causes of Medication Errors
• Patients can contribute to medication errors by
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forgetting to take a dose or doses
taking too many doses
dosing at the wrong time
not getting a prescription filled or refilled in a timely
manner
– not following directions on dose administration
– terminating the drug regimen too soon
Social Causes of Medication Errors
• Social causes may result in an adverse drug
reaction, or a toxic dose
• Over 50% of patients on necessary long-term
medication are no longer taking their medication
after 1 year
• All of these social circumstances would be
considered medication errors
Categories of Medication Errors
• Possible causes of a medication error are
numerous
• Categorizing errors into types aids in identification
and prevention of possible causes
• Categories focus on grouping errors under a set of
common definitions
Edited by Dr. Ryan Lambert-Bellacov
Categories of Medication Errors
• omission error: a prescribed dose is not given
• wrong dose error: a dose is either above or below the
correct dose by more than 5%
• extra dose error: a patient receives more doses than
were prescribed by the physician
• wrong dose form error: dose form or formulation that
is not the accepted interpretation of the physician order
• wrong time error: drug is given 30 minutes or more
before or after it was prescribed
Categories of Medication Errors
• Errors can be classified by what causes the failure
of the desired result
• Errors can be categorized within three basic
definitions of failure:
– human failure
– technical failure
– organizational failure
Categories of Medication Errors
• Human failure is a failure that occurs at an
individual level
– pulling a medication bottle from the shelf based on
memory, without cross-referencing the bottle label with
the medication order/prescription
– errors made by the patient such as non-compliance to
prescribed drug therapy
• Technical failure is a failure resulting from
location or equipment
– incorrect reconstitution of a medication because of a
malfunction of a sterile-water dispenser
– failure to properly operate automated equipment
Root Cause Analysis of Medication
Errors
• Root cause analysis is a logical and systematic
process used to help identify what, how, and why
something happened to prevent reoccurrence
• With basic principles of root cause analysis, any
person can
– examine his or her own work flow to determine the
opportunities for potential error
– determine what type of failure the potential error may be
– create a list of specific potential causes
Root Cause Analysis of Medication
Errors
• Identifying specific potential causes allows a person
to take specific actions to prevent the potential error
• Actions taken improve the quality of work being done
• Common causes of medication error by handlers and
preparers include:
– assumption error
– selection error
– capture error
Root Cause Analysis of Medication
Errors
• assumption error: an essential piece of information
cannot be verified and is guessed or presumed
– misreading an abbreviation on a prescription
• selection error: two or more options exist, and the
wrong option is chosen
– using a look-alike or sound-alike drug instead of prescribed
drug
• capture error: focus on a task is diverted elsewhere
and an error goes undetected
– something captures the person’s attention, preventing the
person from detecting the error or causing an error to be
made
Root Cause Analysis of Medication
Errors
Maintaining focused attention when filling
prescriptions is important to avoid errors.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process in Community
and Hospital Pharmacy Practice
• Review for potential causes of medication error
begins with outlining work tasks in a step-by-step
manner
• Each step in this process can be a
– source of medication error
– place where pharmacy personnel can correct a
medication error
Prescription-Filling Process in Community
and Hospital Pharmacy Practice
Each person who participates in the filling
process has the opportunity to catch and correct
a medication error.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
Outdated prescriptions should not be filled.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
A prescriber’s signature is required for a
prescription to be considered valid.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
Step 1
• Prescribing errors include:
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poor handwriting
using nonstandard abbreviations
confusing look-alike and sound-alike drug names
wrong drug
using “as directed” instructions
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
Step 1
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
A leading zero should precede values less than
one, but a zero should not follow a decimal if
the value is a whole number. A tenfold error
occurs if the decimal point is not detected.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
Step 1
• Opportunities for medication errors increase with the
number of medications a patient takes
– common with many older patients
• Profile review for every prescription should include:
– check for existing allergies and multiple drug therapy
– check for drug interactions or duplication of therapy
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
Check the patient profile for existing allergies
or possible drug interactions.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
:Retrieve Medication
• Products can contribute to errors with
– look-alike labels
– similarities in brand or generic names
– similar pill shapes or colors
• Use NDC numbers, drug names, and other
information to verify selection of the correct product
– use both the original prescription and the generated label
when selecting a manufacturer’s drug product from the
storage shelf
– use NDC numbers as a cross-check
Prescription-Filling Process
Step 5: Fill or Compound Prescription
• Calculation and substitution errors are sources of
medication errors
– write out the calculation and have a second person check
the answer
• Take care when reading labels and preparing
compounded products
Medication Error Prevention
• Preventing medication errors means
– carefully examining potential points of failure
– using available resources to verify information given or
decisions made
• Drug identification is the most common error in
dispensing and administration
Medication Error Prevention
Incorrect drug identification is the most common
error in dispensing or administration.
Edited by Dr. Ryan Lambert-Bellacov
Medication Error Prevention
• Many medication errors occur during prescribing
and administration
• Prescribers are responsible for ensuring the “five
Rs” or five rights
– the right drug
– for the right patient
– at the right strength
– given by the right route
– administered at the right time
Innovations to Promote Safety
• The physical pharmacy work setting can have a
major contribution to the overall safety of any
work environment
• Automate and bar code all fill procedures
• Maintain a clean, organized, orderly work area
• Provide adequate storage areas
• Encourage prescribers to use common
terminology and only safe abbreviations
• Provide adequate computer applications and
hardware
Innovations to Promote Safety
• Innovations can minimize possibility of errors
• In community pharmacy, redesigned packaging helps
patients take medication safely
– Target ClearRx packaging helps patients manage their
medications
• colored rings help patients identify medications intended for
each family member
• clear, easy-to-read label for patient administration
instructions and cautions
• includes a pullout patient information card or printout
Learn more about the Target label design
Innovations to Promote Safety
• In hospital pharmacy, integrated computerized filling
systems allow institutions to
– improve efficiency
– redirect resources
Medication Error and Adverse Drug
Reaction Reporting Systems
• The first step in prevention of medication errors is
collection of information
• Fear of punishment is a concern with errors
– people may decide not to report an error at all
– allows the same error to occur again and again
• Anonymous (no-fault) reporting systems have been
established
– focus on fixing the problem, not fixing the blame
State Boards of Pharmacy
• More than 20 states have mandatory errorreporting systems
– most state officials admit medical errors are still underreported mostly because of fear of punishment
• Some states have worked to reduce the fear of
reporting
– allow pharmacists to document errors and error-prone
systems without worry of punishment
– most boards of pharmacy will not punish pharmacists
for errors
State Boards of Pharmacy
• Pharmacy technicians are an integral part of the
error identification, documentation, and prevention
process
• The final and most important piece of medication
error reporting is informing the patient that a
medication error has taken place
– commonly the task of the pharmacist
State Boards
• The circumstances leading to the error should be
explained completely and honestly
• Patients should understand
– the nature of the error
– what if any effects the error will have
– how they can become actively involved in preventing
errors in the future
• People are more likely to forgive an honest error
Joint Commission on Accreditation for
Healthcare Organizations
• Organizations can create a centralized point through
which all members may channel error information
safely
• The Sentinel Event Policy was created by the Joint
Commission on Accreditation for Healthcare
Organizations (JCAHO) in 1996
• A sentinel event is an unexpected occurrence
involving death or serious physical or psychologic
injury
Joint Commission on Accreditation for
Healthcare Organizations
• When a sentinel event is reported, the organization is
expected to
– analyze the cause of the error (perform a root cause
analysis)
– take action to correct the cause
– monitor the changes made
– determine whether the cause of the error is eliminated
• Accreditation of hospitals depends on demonstrating
an effective active error–reporting system
Learn more about the Joint Commission International Center for Patient
Safety