Transcript Medical errors

Prepared by:
Abdullhadi Burzangy
Introduction
 In USA, Institute of Medicine report on medication
errors (2000):
 Medical errors: 8th leading cause of death, resulting
in 44,000 - 98,000 deaths annually. In contrast,
Highway accidents: 43,458 Breast cancer:
42,297,AIDS: 16,516.
 Medication errors account for an estimated 7,000
deaths & injure approximately 1.3 million people per
year nationally.
Definition of “medication error”
"A medication error is any preventable event that
may cause or lead to inappropriate medication use
or patient harm.
Such events may be related to professional practice,
health care products, procedures, and systems,
including prescribing; order communication;
product labeling, packaging, and; compounding;
dispensing; distribution; administration and use."
Cost of medication errors
• Patients injured as a result of a medication
error stay in a hospital longer and have
higher hospital costs.
• It costs $17-$29 billion annually.
Cost of medication errors
• At the hospital in Utah, adverse drug
events caused complications in 2.4% of
admissions, cost an average of $2,262 per
patient, and lengthened the stay by 1.9
days compared with matched controls.
Medication Errors
• Medication errors can occur anywhere in
these areas :
Prescribing.
Repackaging.
Dispensing.
Administering.
Storage.
The intensity of care also affects the risk
of injury. Among pediatric patients
admitted to a British university hospital,
drug errors were 7 times more likely to
occur in the intensive care unit than
elsewhere
Types of errors
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Wrong drug.
Wrong dose.
Missed dose.
Wrong dosing frequency.
Wrong dosage form.
Wrong time.
Wrong route.
Wrong I.V. rate
Wrong I.V. solution.
Types of errors
• Wrong patient.
• Failure to account for patient
characteristics in making drug therapy
decision.
• Inappropriate indication for use.
• Calculations ,decimal points, unit of
measure.
• Known allergy.
• Expired date .
• Drug interaction.
Common causes of such errors include :
• Poor communication.
• Ambiguities in product names, directions for
use, medical abbreviations or writing.
• Patient misuse because of poor understanding
of the directions for use of the product .
• Work load (30 prescription order/hour).
Causes of medication error
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Doctors orders change frequently.
Names of medicines are similar.
Pharmacy delivers incorrect dose.
Doctor notes is not clear.
Causes of medication error
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Patients on similar medicines.
No communication when next dose due.
Look alike medicines.
Look alike packaging.
Prescription writing
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The following important points should be noted:
Prescription must be printed in English without abbreviations.
Name of the drug should be written clearly &not abbreviated.
Dose & dose interval must be stated.
Computer issued :
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The dose will be in numbers ,frequency in words &quantity in number
in practice. e.g. Amoxycillin cap. 500mg one cap. three times daily
(21).
Hand-written:
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Quantities to be supplied may be stated by indicating the number of
days required for a treatment e.g. Rx Paracetamol tab. 500mg 2×3×7.
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Microgram & nanogram should not be abbreviated.
The unnecessary use of decimal points should be avoided:
Quantities in Rx
Correct method
Wrong way
1- 1 gram or more.
2g
2.0 g
2- less than1gram& more
than 1 milligram.
100 mg
0.1g
3- less than 1 milligram,
written in microgram
100 microgram
0.1mg or 100 μg
If the decimal point cannot be avoided as for value less than 1, write
zero before the value. E.g. 0.5ml not .5 ml.
for liquid , we use milliliter (ml) not cc or Cm3.
Table 1. Commonly Misinterpreted Medical Abbreviations
Abbreviation
Intended Meaning
Possible Misinterpretation
U
Units
Mistaken as a zero or a four (4) resulting in overdose.
µg
Micrograms
Mistaken for "mg" resulting in a 1,000-fold overdose.
QD
Every day
The period after the "Q" has sometimes been mistaken for an "I," and the drug has been
given QID rather than daily.
QOD
Every other day
Misinterpreted as "QD" or "QID." If the "O" is poorly written, it looks like a period or an
"I".
SC or SQ
Subcutaneous
Mistaken as "SL" (sublingual) when poorly written.
TIW
Three times a week
Misinterpreted as "three times a day" or "twice a week".
D/C
Discharge; also discontinue
Patients' medications have been prematurely discontinued when "D/C" was intended to
mean "discharge" versus "discontinue".
HS
Half strength
Misinterpreted as the abbreviation "HS" (hour of sleep).
cc
Cubic centimeters
Mistaken as "U" (units) when poorly written.
AU, AS, AD
Both ears; left ear; right ear
Misinterpreted as the abbreviation "OU" (both eyes); "OS" (left eye); "OD" (right eye.)
Reporting
Human beings make mistakes.
Mistakes can be prevented by designing
systems “that make it hard for people to
do the wrong thing and easy for people to
do the right thing.”
To design such systems and evaluate their
effectiveness, we need to start with
baseline information.
Benefits of reporting medication
errors:
*To decrease the incidence of medication
errors.
*For Patients safety.
* To improve each step in the medication
delivery process.
Benefits of reporting medication
errors:
*To improve clinical practice and quality
of care.
*To Educate patients regarding strategies
to prevent medication errors.
*To maximize the safe use of medications.
Benefits of reporting medication
errors:
*Identify gaps in research that hinder the
understanding of medication errors.
*Promote research to expand knowledge
regarding medication errors, their causes,
and the effectiveness of interventions.
Medication-error Reporting
Reporting of medication errors is crucial
…but traditionally punitive.
If reporting is inadequate, we cannot identify
problems.
Studies conclude that 45-95% of medication
errors are not reported.
Why are medication errors not
reported?
• Administration looks at individual not system.
• Nurses are blamed if something happen to patient
due to error.
• Nurses fair adverse consequences from reporting
• Nurses believe peers will think them incompetent .
• Nurses don’t think error is important enough.
Why are medication errors not
reported?
• Patient / family may sue.
• No positive feedback when medication given
correctly.
• Response from administration dose not match
the severity.
• Report takes too long to complete.
Medication error reporting
• Increase awareness of reporting system available to or within
health care organization .
• Stimulate & encourage reporting of medication errors both
locally &nationally.
• Develop standardization &classification for the collection of
medication errors reports so that data base will reflect reports
&grading system.
• Maintain system to support & provide feedback to reporters so
that appropriate prevention strategies can be developed in
facilities.
Medication error prevention
• Encourage standardization of error-prone aspect of
prescribing, delivering & administrating.
• Encourage reliance on system-based solutions to
enhance the safety of medication use & to minimize
the potential for human error.
• Explore the potential for computer-based
information systems in the prevention of medication
error.
Medication error prevention
• Increase awareness of the need for distinctive
packaging, labeling& nomenclature of product
associated with actual or potential medication error.
• Educate consumers and patient regarding strategies
to prevent medication error for both prescription and
nonprescription medication.
• Educate health care professional regarding
strategies to prevent medication error .
Medication error prevention
• Presence of a drug information service.
• Pharmacist-provided drug protocol management.
• Pharmacist-participation in medical rounds.
• Increase staffing of clinical pharmacist.
Medication error prevention
• Pharmacists fill no more than 15 prescriptions / hour.
• Avoid verbal drug orders.
• Avoid abbreviations.
• Use of medication-dispensing machines.