Transcript Medication Safety & Medication Errors PHCL 311 Lecture 1

Medication Safety &
Medication Errors
Part I
PHCL 311
Hadeel Al-Kofide MS.c
Topics to be covered today
• Introduction
• The evidence that medication error is a problem
• Definitions
• The relationship between medication error, ADE & ADE
• Classifications & types of medication error
• Reasons for medication errors
• How to prevent medication error
Introduction
• The goal of drug therapy is the achievement of defined
therapeutic outcomes that improve a patient’s quality of life
while minimizing patient risk
• With every therapy there must be a risk, it could be known or
unknown
• These risks are defined as drug misadventures, which includes
both adverse drug reactions (ADRs) & medication errors
Definitions
• Medication error
• Adverse drug event (ADE)
• Adverse drug reaction (ADR)
Definitions
Adverse Drug Events (ADE)
• Any injury caused by a medicine or lack of intended
medication
 Adverse drug reactions & overdoses
 Dose reductions & discontinuations of drug therapy
Definitions
Adverse Drug Reaction (ADR)
• Any unexpected, unintended, undesired, or excessive response
to a drug, with or without an “injury”
• Harm directly caused by the drug at normal doses,
during normal use
Definitions
Medication Error (ME)
• Any preventable event that has the potential to lead to
inappropriate medication use or patient harm during
prescribing, transcribing, dispensing, administering,
adherence, or monitoring a drug
• Medication errors that are stopped before harm can occur are
sometimes called “near misses” or more formally,
a potential adverse drug event
The Relationship Among ME, ADEs, &
ADRs
Medication
Errors
ADEs
ADRs
Nebecker et al. Ann Intern Med 2004;140: 795-801, J Gen Med 10:199-205,1995.
What Is The Evidence That Patient
Safety Is A Problem?
ME is A Problem
Evidence That ME is A Problem
• Medications harm at least 1.5 million people per year
• 44,000 to 98,000 hospitalized Americans die each year from
medical error
• Errors cause more death each year than breast cancer, motor
vehicle accidents & AIDS
Institute of Medicine. Preventing medication errors: quality chasm series, 2006
ME is A Problem
Evidence That ME is A Problem
• The financial burden from these medical errors that is
estimated to be in a range of $30 billion to $130 billion
annually
• Up to 28% of these events are thought to be preventable
White TJ et al, Pharmacoeconomic. 1999, Classen DC et al, JAMA. 1997
ME is A Problem
Medication Error Deaths Increasing
Deaths from
Medication Errors
1983
Phillips DP. Annu Rev Public Health. 2002;23:135-50.
1998
Types & Classification of
Medication Errors
Types & Classification of ME
• NCC MERP index for categorizing medication errors
• Medication use process
• Three major areas for medication error:
 Prescribing
 Dispensing
 Administration
NCC MERP Index for Categorizing Errors
Medication Safety &
Medication Errors
Part II
PHCL 311
Hadeel Al-Kofide MS.c
Topics to be covered last lecture
• Introduction
• The evidence that medication error is a problem
• Definitions
• The relationship between medication error, ADE & ADE
• Classifications & types of medication error
• Reasons for medication errors
• How to prevent medication error
Topics to be covered today
• Focusing on error prevention
• Identifying medication error
• How to approach error (Person Vs. System)
• Methods used to minimize or reduce medication errors
• Establishing a culture of safety (Building a safer healthcare
system )
• Medication error reporting system
The Medication Use System
High-Level Portrayal of a Medication Use System
Selection &
Procuring
Establish
formulary
Clinician &
administrators
Joint Commission. 1998
Prescribing
Assess patient;
determine need
for drug
therapy; select
& order drug
Physician/
prescriber
Preparing &
Dispensing
Purchase &
store drug;
review &
confirm order;
distribute to
patient location
Pharmacist
Administering
Review
dispensed drug
order; assess
patient &
administer
Nurse/other
health
professionals
Monitoring
Assess patient
response to
drug; report
reactions &
errors
All
practitioners,
plus patient
&/or family
Major Areas for Medication Error
• Medication errors can be broadly classified as
 Prescribing
 Dispensing
 Drug administering errors
Major Areas for Medication Error
39%
38%
12%
Medication Errors Reporting Program US
11%
Types of ME
Prescribing Errors
• It is an incorrect drug selection for a patient. Such errors can
include the dose, strength, route, quantity, indication, or
prescribing contraindicated drug
• This definition can be further expanded to include failure to
comply with legal requirements for prescription writing
Williams DJ. 2007,
Lesar et al. JAMA. 1997
Types of ME
Prescribing Errors
Contributing factors:
• Illegible handwriting
• Inaccurate medication history taking
• Confusion with the drug name
• Inappropriate use of decimal points
• Use of abbreviations (e.g. AZT has led to confusion between
Zidovudine & Azathioprine)
•
Use of verbal order
Williams DJ. 2007
Prescribing Errors….. Examples
Name That Drug…
Lipitor 10mg PO QD
Filled Rx: Zyrtec 10mg
Prescribing Errors….. Examples
Name That Drug…
6 unties of regular insulin now
Filled Rx: 60 units
Prescribing Errors….. Examples
Name That Drug…
Tegretol 300mg BID
Filled Rx: Tegretol 1300mg
Prescribing Errors….. Examples
Name That Drug…
Filled Rx: Coumadin 2mg PO HS & Coumadin 4mg PO
QAM
Cardura 2mg PO HS &
Patient receivedAvandia
6mg of Coumadin
PLUS
no treatment for
4mg PO
QAM
hypertension & diabetes
Prescribing Errors…..Examples
Sometimes the technology itself is the problem…
Monopril 40mg
Filled Rx: Monopril 10mg
Dispensing Errors
• It is an error that occurs at any stage during the dispensing
process from the receipt of a prescription in the pharmacy
through to the supply of a dispensed product to the patient
• Studies have estimated that dispensing errors occur at a rate of
1-24%
• These errors include the selection of the wrong
strength/product. This occurs primarily when ≥ 2 drugs have a
similar appearance or similar name (look-a-like/sound-a-like
errors)
Dispensing Errors…..Examples
Dispensing Errors…..Examples
Dispensing Errors…..Examples
Dispensing Errors…..Examples
Rx
AXERT (almotriptan) 6.25 mg 1-2 tablets at once, & repeat in
2 hours if needed up to 25 mg/day
Dispensed
ANTIVERT (meclizine)
Dispensing Errors…..Examples
Rx
Keppra (anticonvulsant) 500 mg every 12hours
Dispensed
Kaletra (antiviral)
Administration Errors
• Defined as a discrepancy between the drug therapy received by
the patient & the drug therapy intended by the prescriber
• Drug administration is associated with one of the highest risk
areas in nursing practice
Administration Errors
• Drug administration errors largely involve errors of omission
where administration is omitted due to a variety of factors e.g.
wrong patient, lack of stock
• Other types of drug administration errors include wrong
administration technique, administration of expired drugs &
wrong preparation administered
Administration Errors
Contributing factors:
• Failure to check the patient’s identity prior to administration
• Storage of similar preparations in similar areas
• Noise, interruptions while undertaking a drug round, & poor
lighting
•
Errors
Williams DJ. 2007
• More than one tablet for a single dose
• Calculation is required to determine the
correct dose
Administration Errors…..Examples
A patient had an epidural line for pain management & a
peripheral IV line containing insulin

The nurse caring for the patient was busy & asked a second
nurse to retrieve the next scheduled epidural infusion bag

The second nurse delivered a new bag of insulin to the
patient’s bedside
Without checking the label, the primary nurse hung the insulin
infusion to the epidural line
Reasons For Medication Errors
1. Ambiguous strength
designated on labels or in
packaging
5. Improper transcription &
inaccurate dosage
calculation
2. Drug product nomenclature
(look-alike or sound-alike
names, use of lettered or
numbered prefixes &
suffixes in drug name)
6. Inadequately trained
personnel
3. Equipment failure or
malfunction
9. Excessive workload
4. Illegible writing
7. Inappropriate abbreviations
8. Labeling errors
10. Lapses in individual
performance
11. Medication unavailable
Focusing on Error Prevention
Can We Do Anything About These
Errors?
Step One
See the problem
Can We Do Anything About These
Errors?
Step Two
Identify
The Risk
& Manage It
Identifying Medication Error
How Can We Identify The Risk?
• High alert medication
• Error prone notations
• Look-a-like & sound-a-like medications
High Alert Medications
• What are high alert medications?
• How can we reduce the error associated with high alert
medications?
High Alert Medications
"Top 10" Medications Involved in Drug
Errors
Agent
% of Drug Errors Associated with
Acute Hospital Care
Insulin
4% of all medication errors in 2005
Morphine
2.3%
Potassium Chloride
2.2%
Albuterol
1.8%
Heparin
1.7%
United States Pharmacopeia.2007
High Alert Medications
"Top 10" Medications Involved in Drug
Errors
Agent
% of Drug Errors Associated with
Acute Hospital Care
Vancomycin
1.6%
Cefazolin
1.6%
Acetaminophen
1.6%
Warfarin
1.4%
Furosemide
1.4%
United States Pharmacopeia.2007
High Alert Medications
Strategies To Reduce Risk From HighAlert Medications
• Limit the access to these medications
• Standardizing the ordering/preparation & administration
• Independent double check at dispensing & administrating
phase
Error-Prone Notations
• Ambiguous medical notations are one of the most common &
preventable causes of medication errors
• Misinterpretation may lead to mistakes that result in patient
harm
• Delay start of therapy due to time spent for clarification
Error Prone Notations
Implement “Do Not Use” List
• ISMP & FDA recommend that ISMP’s list of error-prone
abbreviations be considered whenever medical information is
communicated
Complete list is located at:
www.ismp.org/Tools/errorproneabbreviations.pdf
ISMP= Institute for Safe Medication Practices,
FDA= Food and Drug Administration
Error Prone Notations
Short List of Error-Prone Notations*
Notations should NEVER be used
Notation
Reason
Instead Use
U
Mistaken for 0, 4, cc
Unit
IU
Mistaken for IV or 10
Unit
QD
Mistaken for QID
Daily
QOD
Mistaken for QID, QD
* Comprises “Do Not Use” list required for JCAHO accreditation
“every other day”
Error Prone Notations
Short List of Error-Prone Notations*
Notations should NEVER be used
Notation
Reason
Instead Use
Trailing zero (X.0
Decimal point missed
“X mg”
Decimal point missed
“0.X mg”
Mistaken for U
“mL”
Can mean Morphine Sulfate
“Morphine Sulfate”
mg)
Naked decimal
Point (.X mg)
cc
MS
or Magnesium Sulfate
* Comprises “Do Not Use” list required for JCAHO accreditation
Error Prone Notations
Short List of Error-Prone Notations*
Notations should NEVER be used
Notation
Reason
Instead Use
> or <
Mistaken as opposite of
“greater than” or
intended
“less than”
μ
Mistaken for mg
“mcg”
@
Mistaken for 2
“at”
/
Mistaken for 1
* Comprises “Do Not Use” list required for JCAHO accreditation
“per”
Error Prone Notations
Short List of Error-Prone Notations*
Notations should NEVER be used
Notation
Reason
Instead Use
+
Mistaken for 4
“and”
D/C, dc, d/c
Misinterpreted as when
“discontinued” followed by
list of medications
* Comprises “Do Not Use” list required for JCAHO accreditation
“discharge”
or
“discontinued”
Error Prone Notations
Error-Prone Notations…..Examples
Intended dose of 4 units
Administered 44 units
Should be written as “4 units”
Error Prone Notations
Error-Prone Notations…..Examples
Intended dose of “.4 mg”
Administered 4mg
Should be written as “0.4 mg.”
Error Prone Notations
Strategies To Reduce The Risk From
Error Prone Notations
• NEVER use notations
Approaches to Reduce Medication
Errors
Approaches to Reduce Medication
Errors
• Person-centered approach
• System centered approach
• The Swiss cheese model of systems errors
Approaches to Reduce Medication
Errors
 Person-Centered Approach
• It has been traditional used in analysis of medication errors
• It looks at medication errors as occurring due to human frailty,
including
Forgetfulness
Poor motivation
Carelessness, not paying attention
Negligence
Approaches to Reduce Medication
Errors
 System-Centered Approach
• Errors expected to occur
• Errors are viewed as the end result & not the cause
• There is potential for error & recurring errors in every system,
& even the best systems fail
Approaches to Reduce Medication
Errors
 System-Centered Approach
• Solutions are based on the belief that conditions can be
changed, rather than focusing on changing humans
• Barriers & safeguards should be implemented to help prevent
errors
• It is essential to focus on how & why the system failed & not
on which individual failed
Methods Used to Minimize or
Reduce Medication Errors
Reducing Medication Error
• Steps to minimize medication error
• Prescriber actions
• Pharmacy (dispensing) actions
• Nurse (administrator) actions
Steps to Minimize Medication Error
Most
effective
Forcing functions & constraints
Automation & computerization
Standardization & protocol
Checklist & double check system
Least
effective
Rules & policies
Education/ Information
Be more careful, be vigilant
Steps to Minimize Medication Error
Forcing functions & constraints
• Use pharmacy system that will not fill any order unless allergy
information, patient weight & height are entered
• Use computer order entry with dosage checks
• Remove dangerous IV drugs (e.g. conc. potassium, hypertonic
sodium chloride) from ward stock
• Limit choices of available drugs in pharmacy
• Limit dosage strengths & concentration for each drug
• Mix IVs in the pharmacy
Steps to Minimize Medication Error
Automation & computerization (Reduce reliance on memory)
• Use drug-drug interaction checking system
• Use computerized order entry
• Use computerized patient information
• Use bar-coding on drugs, containers, medication records,
patient wristbands
• Automated dispensing on patient care unit
Steps to Minimize Medication Error
Standardization & protocol
• No error –prone abbreviations
• Use generic names rather then brand name
• Use standard equipment—one kind of pump or syringe
• Use protocol for complex medication administration e.g.
heparin, chemotherapy
Prescriber Action to Reduce ME
• Stay current & knowledgeable concerning changes in
medication & treatment
• Utilize pharmacist consultation if available
• Ensure that drug orders are complete, clear, unambiguous &
legible
 Including patient weight, dosage (mg/kg/dose or/day), frequency &
route of administration
 Avoid use of terminal zero e.g. use 5 rather 5.0
 Use a zero to the left of a zero ( use 0.2 rather .2 )
• Discuss medication changes with nursing & other staff &
families
Pharmacy Action to Reduce ME
• Independent double check orders both on calculation &
preparation
• Clarify confusing orders
• Checking for current patient drug allergy
• Dispense medication using unit-dose, ready to administration
form whenever possible
• Patient name, generic drug name, patient specific dose on all
labels
Nursing Action to Reduce ME
• Double check medication calculations
• Verify drug order & confirm patient identity & weight before
administration
• Have access to drug information on all medications
• Familiar with the operation of medication administration
device
Medication Error Reporting
Systems
Medication Error Reporting System
• International systems
• National system
• Local (in hospital or healthcare setting) system
• No system
International Systems
• The Medication Error Reporting Program operated by United
States Pharmacopoeia in cooperation with the ISMP
• The Joint Commission on Accreditation of Healthcare
Organization (JCAHO) sentinel event reporting system
• The FDA MedWatch program
• MEDMARX®
• The National Coordinating Council for Medication Error
Reporting and Prevention (NCC MERP)
Pharmacovigilance
• Data gathering related to the detection, assessment,
understanding, and prevention of adverse events
• Identifying new information about hazards associated with
medicines, preventing harm to patients
• Medical errors are broader category which includes adverse
reactions but also other factors (diagnostic errors, equipment
failure, nosocomial infections ... )
The Role of Pharmacists in
Medication Error Prevention
How Can Pharmacists Reduce ME?
• Clinical pharmacist
• Drug & poison information pharmacist
• Staff pharmacist
• Medication safety pharmacist??
Pharmacist on Patient-Care Team
• A full-time unit-based clinical pharmacist substantially
decreased the rate of serious medication errors in ICU by 66%
• Studies shows that clinical pharmacy services & increase
hospital pharmacy staffing are associated significantly with
reduction in medication errors
Leape LL et al. JAMA.1999,
Kaushal R et al. American Journal of Health-System Pharmacy.2008
Clinical Pharmacy & ME Reduction
• Drug histories
51%
• Drug information services
18%
• Adverse drug reaction monitoring
13%
• Drug protocol management
38%
• Medical rounds participation
29%
Bond CA et a. Pharmacotherapy.2002
Always remember
“to Err is Human!”