Transcript Medical Errors

Chapter 12
Medication Safety
© Paradigm Publishing, Inc.
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Medical Errors
• Medical errors result in unintended
health outcomes.
• As many as 98,000 people die each
year in the US as a result of medical
errors.
• The pharmacy technician should be
on the lookout for potential medical
errors.
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Terms to Remember
medical error
any circumstance, action, inaction, or
decision related to health care that
contributes to an unintended health
result
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Medication Errors
• Medication errors are among the most
common types of medical errors.
• Medication errors result in an
estimated 7,000 deaths each year in
the US.
• About 1.7% of all prescriptions
dispensed in a community pharmacy
contain a medication error.
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Terms to Remember
medication error
any preventable event that may cause or
lead to inappropriate medication use or
patient harm while the medication is in
the control of the healthcare
professional, patient, or consumer
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Medication Errors
• Patient response
• Categories of medication errors
• Root-cause analysis of medication
errors
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Patient Response
• Some medication errors have a
physiological cause.
• Medications may not be properly
eliminated from the body due to
– An enzyme deficiency
– Decreased kidney function
• If the dose is not lowered, the
medication may reach toxic levels.
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Patient Response
• Some medication errors have a social
cause.
• Patients can cause medication errors
through incorrect self-administration:
– Forgetting to take a dose or taking it at the
wrong time
– Taking too many doses
– Not getting a prescription filled or refilled in a
timely manner
– Not following dosing directions
– Terminating the regimen too soon
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Categories of Medication
Errors
• Omission error: prescribed dose not given
• Wrong dose error: dose given is 5% above or
below correct dose
• Extra dose error: more doses given than
prescribed
• Wrong dosage form error: dosage form
incorrectly interpreted
• Wrong time error: dose given at least 30
minutes before or after prescribed time
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Terms to Remember
omission error
an error in which a prescribed dose is
not given
wrong dose error
an error in which the dose is either
above or below the correct dose by
more than 5%
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Terms to Remember
extra dose error
an error in which more doses are
received by a patient than were
prescribed by the physician
wrong dosage form error
an error in which the dosage form or
formulation is not the accepted
interpretation of the physician order
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Terms to Remember
wrong time error
a medication error in which a drug is
given 30 minutes or more before or after
it was prescribed, up to the time of the
next dose, not including as needed
orders
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Categories of Medication
Errors
• Medication errors can also be
categorized by the cause of failure.
• Human failure: an
individual mistake
by the healthcare
worker or patient
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Terms to Remember
human failure
an error generated by failure that occurs
at an individual level
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Categories of Medication
Errors
• Technical failure: an equipment
malfunction
• Organizational failure: error caused
by rules, policies, or procedures
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Terms to Remember
technical failure
an error generated by failure because of
location or equipment
organizational failure
an error generated by failure of
organizational rules, policies, or
procedures
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Root-Cause Analysis
of Medication Errors
• Process to identify what, how, and why
something happened
• List of specific potential causes identified
• Three of the most common causes
– Assumption errors
– Selection errors
– Capture errors
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Terms to Remember
root-cause analysis
a logical and systematic process used to
help identify what, how, and why
something happened, in order to prevent
recurrence
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Terms to Remember
assumption error
an error that occurs when an essential
piece of information cannot be verified
and is guessed or presumed
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Root-Cause Analysis
of Medication Errors
Examples
Assumption error: when a pharmacy
technician misreads a poorly-written
abbreviation on a prescription
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Terms to Remember
selection error
when two or more options exist and the
incorrect option is chosen
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Root-Cause Analysis
of Medication Errors
Examples
Selection error: when
a pharmacy technician
mistakenly selects
a look-alike or
sound-alike drug
instead of the
prescribed drug
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Terms to Remember
capture error
an error that occurs when focus on a
task is diverted elsewhere and therefore
the error goes undetected
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Root-Cause Analysis
of Medication Errors
Examples
Capture error: when a pharmacy
technician takes a phone call in the middle
of filling a prescription and thus miscounts
the number of tablets
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Root-Cause Analysis
of Medication Errors
Safety Note
Maintaining focused attention when
filling prescriptions is important to
avoid errors.
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Prescription-Filling Process
• To find potential causes for medication
errors, it is helpful to examine each step of
the prescription-filling process.
• There are three parts to each step:
– Information that needs to be obtained or
checked
– Resources that can be used to verify
information
– Potential errors that might result from a failure
to check or obtain information
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Prescription-Filling
Process
Safety Note
Each person who participates in the
filling process has the opportunity to
catch and correct a medication
error.
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Prescription-Filling Process
• Step 1: Receive and review
prescription.
• Step 2: Enter prescription into
computer.
• Step 3: Perform drug utilization review
and resolve medication issues.
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Step 1: Receive and Review
Prescription
• Is the prescription legible?
– If not, check with physician, nurse, or
pharmacist.
• Is the prescription valid and legal?
– Be familiar with state requirements.
– Check with physician, pharmacist, or
nurse, if necessary.
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Step 1: Receive and
Review Prescription
Safety Note
Careful review of the prescription or
order is very important.
Outdated prescriptions should not
be filled.
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Step 1: Receive and
Review Prescription
Safety Note
A prescriber’s signature is required
for a written prescription to be
considered valid.
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Step 1: Receive and Review
Prescription
Prescriptions contain three basic types
of information:
– Physician information
– Patient information
– Medication information
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Step 1: Receive and Review
Prescription
Physician information must be sufficient
to determine whether the prescription
was written by a qualified prescriber:
– Contact information
– Signature
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Step 1: Receive and Review
Prescription
Patient information should be detailed
enough to pinpoint the individual:
– Full name
– Address
– Date of birth
– Phone number
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Step 1: Receive and Review
Prescription
Medication information must be
unambiguous:
– Drug name
– Dose and dosage form
– Route of administration
– Refills or length of therapy
– Directions for use
– Dosing schedule
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Step 1: Receive and
Review Prescription
Safety Note
A leading zero should precede
values less than 1, but a zero
should not follow a decimal if the
value is a whole number.
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Step 2: Enter Prescription
into Computer
• Data entry involves inputting into the
computer information from the hard
copy of the prescription.
• Several pieces of information need to
be checked to ensure that the patient
receives the correct, drug, dose, and
dosage formulation.
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Step 2: Enter Prescription
into Computer
Do the drug choices on the computer
screen include the exact drug on the
prescription?
May need to
cross-check
brand names
and generic
names.
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Step 2: Enter Prescription
into Computer
• Does the spelling on the prescription match
the drug selection?
• Do the units and increments of measure
(gram, milligram, microgram) on the drug
selection options match those on the
prescription?
May need to cross-check the measure
prescribed.
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Step 2: Enter Prescription
into Computer
• For the dose selected, do the available
strengths or concentrations match?
• Does the dose or concentration have
leading or trailing zeros, and does it require
a decimal?
Cross-check doses that contain leading or trailing
zeros.
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Step 2: Enter Prescription
into Computer
• Do the available forms match the
prescribed route of administration?
• The pharmacist and
the technician should
check each piece
of entered
information before
proceeding.
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Step 3: Perform DUR and
Resolve Medication Issues
• For every prescription, the pharmacy
technician should complete a
computerized DUR of the patient
profile to check for allergies and
multiple drug therapies.
• The pharmacist should perform a
medication review to check for drug
interactions and duplication of
therapy.
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Step 3: Perform DUR and
Resolve Medication Issues
Safety Note
Check the patient profile for existing
allergies or possible drug
interactions.
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Step 3: Perform DUR and
Resolve Medication Issues
Dosage must be carefully checked for
– Pediatric patients
– Geriatric patients, where age-related
declines in liver and kidney function may
necessitate a lower dosage
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Prescription-Filling Process
• Step 4: Generate prescription label.
• Step 5: Retrieve medication.
• Step 6: Fill or compound prescription.
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Step 4: Generate Prescription
Label
• The computer-generated label should be
compared with the original prescription.
• Has the patient information been crosschecked?
• Are the label and the prescription identical?
• Are the leading and trailing zeros and
unapproved abbreviations correct?
• Do all the data elements on the label match
those on the prescription?
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Step 5: Retrieve Medication
• Use both the original prescription and
the computer-generated label when
selecting a drug product from storage.
• Drug look-alikes and sound-alikes can
cause accidental substitution.
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Step 5: Retrieve Medication
Safety Note
Confirm that information entered
into the computer matches that in
the original prescription.
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Step 5: Retrieve Medication
Has information on the manufacturer’s
label been used to verify the medication
selection?
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Step 5: Retrieve Medication
Be sure the label and the product
container match in terms of
– Brand name
and generic
name
– Dose strength
and form
– NDC and
manufacturer
name
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Step 6: Fill or Compound
Prescription
• Calculation and substitution errors are
frequent sources of pharmacy-related
medication errors.
• Do not allow interruptions or
distractions during filling or
compounding.
• All equipment should be maintained,
cleaned, and calibrated regularly.
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Step 6: Fill or Compound
Prescription
Safety Note
When compounding, do not allow
interruptions. Prepare products one
at a time.
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Step 6: Fill or Compound
Prescription
• Have the amount to be dispensed and the
increment of measure been verified?
– Check the original prescription.
– Count the medication twice.
• Does the prescription require a calculation
or conversion?
– Write out the calculation or conversion.
– Have another person review it.
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Step 6: Fill or Compound
Prescription
• Has the equipment been calibrated
recently?
– Check the calibration.
– Verify it with the pharmacist.
• Does the medication require warning or
caution labels?
– Check the patient information handout and the
package insert.
– Check with the pharmacist.
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Prescription-Filling Process
• Step 7: Review and approve
prescription.
• Step 8: Store completed prescription.
• Step 9: Deliver medication to patient.
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Step 7: Review and
Approve Prescription
Safety Note
The pharmacist must always check
the technician’s work.
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Step 7: Review and Approve
Prescription
• The pharmacist is legally responsible for
verifying the accuracy of any prescription
that is filled.
• The pharmacy technician should provide all
available resources that are useful to
ensure accurate verification.
• The pharmacist should be able to retrace
the technician’s steps in filling the
prescription.
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Step 7: Review and Approve
Prescription
• Did the pharmacist review the
prepared medication?
• Given the information provided, can
the pharmacist verify
– The validity of the prescription?
– The patient information?
– The correctness of the prepared
prescription?
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Step 8: Store Completed
Prescription
• Ensuring integrity of medications is an
important part of medication safety.
• Many medications are sensitive to light,
humidity, or temperature and must be
stored appropriately.
• A well-organized and clearly labeled
storage system can keep a patient’s
medications together and separate from
those of other patients.
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Step 8: Store Completed
Prescription
• Are the storage conditions
appropriate for the medication?
• Are each patient’s medications
adequately separated?
• Are the storage areas neat and
orderly?
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Step 9: Deliver Medication
to Patient
In a community pharmacy, the
technician should confirm the patient’s
identity, usually by verifying
– Address
– Date of birth
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Step 9: Deliver Medication
to Patient
The “show-and-tell” technique can be
used to prevent
medication
errors and
provide patient
education.
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Step 9: Deliver Medication
to Patient
In a hospital setting, a nurse or
caregiver is another person to confirm
the accuracy of the medication.
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Step 9: Deliver Medication
to Patient
Safety Note
Pharmacy technicians cannot
instruct patients. If a technician
suspects that a patient requires
instruction, the technician should
alert the pharmacist.
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Step 9: Deliver Medication
to Patient
• Will the appearance of the pill be new to
the patient?
• Is the patient receiving medication intended
for him or her?
• Does the patient understand the
instructions for use?
• Does the patient know what to expect?
• Are all of the prescribed medications
included?
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Medication Error Prevention
The pharmacy technician often has the
most opportunities to prevent a
medication error:
– The first person to examine the
prescription
– The last person to handle a medication
before it reaches a patient
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Medication Error Prevention
• Prescribers are responsible for ensuring
the “five Rs”:
–
–
–
–
–
Right patient
Right drug
Right strength
Right route of administration
Right time
• Pharmacy practice overlays the prescriber
responsibilities and enhances patient
safety.
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Medication Error
Prevention
Safety Note
Incorrect drug identification is the
most common error in dispensing
and administration.
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Medication Error Prevention
• The responsibility of the healthcare
professionals
• Patient education
• Innovations to promote safety
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The Responsibility of the
Healthcare Professionals
• Healthcare workers must put safety
first.
• Pharmacists and pharmacy
technicians can work together to
increase the margin of safety.
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The Responsibility of the
Healthcare Professionals
Safety Note
The only acceptable level for
medication errors is zero errors.
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The Responsibility of the
Healthcare Professionals
Safety Note
If information is missing from a
prescription or medication order,
never assume. Obtain the missing
information from the prescriber.
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Patient Education
• Patients and caregivers must have
the basic knowledge needed to safely
administer medication.
• Pharmacy technicians cannot counsel
patients, but they can encourage
patients to become informed about
their condition and to ask questions.
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Innovations to Promote
Safety
• Automate and bar-code all fill procedures.
• Maintain a clean, organized, and well-lit
work area.
• Provide adequate storage areas with clear
drug labels on the shelves.
• Encourage prescribers to use common
language and only safe abbreviations.
• Provide adequate computer applications
and hardware.
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Innovations to Promote
Safety
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Innovations to Promote
Safety
• eMAR allows the administration of
medication to be documented
electronically rather than on paper.
• eMARs can reduce
dispensing and
administration
errors by 75%.
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Terms to Remember
eMAR
an electronic medication administration
record that is used to minimize
medication errors
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Medication Error Reporting
Systems
• The first step in preventing medication
errors is to identify problems.
• Fear of punishment is always a
concern.
• Anonymous or no-fault reporting
systems have been developed.
• The focus is on fixing the problem, not
assigning blame.
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Medication Error Reporting
Systems
•
•
•
•
•
State boards of pharmacy
The Joint Commission
United States Pharmacopeia
Institute for Safe Medication Practices
Personal prevention strategies
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State Boards of Pharmacy
• Many states have mandatory error
reporting systems.
• Most officials admit that errors are
under-reported due to fear of
punishment.
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State Boards of Pharmacy
• Most state boards of pharmacy do not
punish pharmacists for errors as long
as a good-faith effort was made to fill
the prescription correctly.
• Some states are also considering new
laws that protect error reports from
subpoena.
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The Joint Commission
• The Joint Commission established the
Sentinel Event Policy in 1996.
• A sentinel event is an unexpected
occurrence involving death, serious
physical or psychological injury, or the
potential for such an occurrence to
happen.
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Terms to Remember
sentinel event
an unexpected occurrence involving
death or serious physical or
psychological injury or the potential for
such occurrences to happen
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The Joint Commission
For sentinel events, the organization is
expected to
– Analyze the cause of the error
– Take action to correct the cause
– Monitor the changes made
– Determine whether the cause of the
error has been eliminated
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United States Pharmacopeia
• USP supports the MEDMARX medication
error reporting system.
• MEDMARX allows users to anonymously
document, analyze, and track adverse
events specific to an institution.
• Data from MEDMARX suggests that
contributing factors to errors include
distraction in the workplace, excessive
workload, and inexperience.
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Terms to Remember
MEDMARX
an Internet-based program of the USP
for use by hospitals and healthcare
systems for documenting, tracking, and
identifying trends for adverse events and
medication errors
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Terms to Remember
Institute for Safe Medication Practices
(ISMP)
a nonprofit healthcare agency whose
primary mission is to understand the
causes of medication errors and to
provide time-critical error reduction
strategies to the healthcare community,
policymakers, and the public
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Institute for Safe
Medication Practices
• USP and ISMP provide a confidential
program called the Medication Error
Reporting Program (MERP).
• MERP is designed to allow medical
professionals to report medication
errors directly.
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Terms to Remember
Medication Error Reporting Program
(MERP)
a USP program designed to allow
healthcare professionals to report
medication errors directly to the Institute
for Safe Medication Practices (ISMP)
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Institute for Safe
Medication Practices
MERP medication errors include
– Incorrect drug, strength, or dose
– Confusion over look-alike or sound-alike
drugs
– Incorrect route of administration
– Calculation or preparation errors
– Misuse of medical equipment
– Errors in prescribing, transcribing,
dispensing, or monitoring medications
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Terms to Remember
MedWatch
a voluntary program run by the FDA for
reporting serious adverse events for
medications and medical devices;
serves as a clearinghouse for
information on safety alerts and drug
recalls
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Institute for Safe
Medication Practices
ISMP makes these recommendations to
minimize dispensing errors:
– The order-entry person should be
different from the person who fills the
order.
– Prescriptions should not be prepared
from the computer-generated label but
from the original prescription.
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Institute for Safe
Medication Practices
Recommendations (continued)
– Keep the original prescription, stock
bottle, computer label, and medication
container together during the filling
process.
– The pharmacist should verify dispensing
accuracy by comparing the original
prescription with the labeled product with
the NDC code of the manufactured
product.
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Personal Prevention
Strategies
The pharmacy technician must take
care of himself or herself:
– Get adequate sleep.
– Exercise regularly.
– Take breaks at work.
– Be wise about food.
– Avoid alcohol.
– Cut the caffeine.
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