Transcript Medication_Errors - Maryland Department of Health and Mental

Medication Errors
Medication errors can occur at many
points in a highly complex process,
involving many hands and decision
points, from prescribing and ordering
through administration and
monitoring. Medication errors may or
may not result in an adverse event.
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MEDICATION USE PROCESS
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PRESCRIBING
ORDER PROCESSING
DISPENSING
MEDICATION ADMINISTRATION
MONITORING
ERROR THEORY
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Error theory tells us that errors are common, and more so in
complex systems. Preventing medication errors demands a
mental balance of commitment to a zero error standard
(knowing that the goal is unachievable) and a recognition of the
inherent toxicities and risks associated with medication use.
Unfortunately in an organization where there is unwillingness to
accept that healthcare workers are human and make mistakes,
the result is an environment where errors are hidden and
denied. The end result is finding a focus of blame, rather than
understanding why the error occurred and how to prevent its
occurrence in the future.
ERROR CATEGORIES FOR
MEDICATION USE
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Practitioner knowledge of the drug and access to current and up-to-date
resources
Labeling packaging and nomenclature anomalies (e.g. look-alike packages,
strength confused with vial size, etc)
Dosing errors
Access to adequate patient information and skills and methods to provide
information/access
Accuracy of order transcription, including interpretation and action when a gap
exists
Adequate allergy information and active use of that information
Medication order accuracy and tracking
Communication with patient and other health professionals, including, but not
limited to, patient and family education regarding potential adverse effects,
proper dosage or noncompliance
Minimize influence of environmental factors (e.g., drug storage/stocking, noise
and distractions, adequate workspace)
CASE STUDY
MS was a healthy, seven-pound (3.2kg) newborn whose mother had a history of
syphilis. A language barrier existed, and it was difficult to determine if she had
been treated properly or if the infection persisted. Shortly after MS' birth a
neonatologist was consulted, and it was determined that the infant should be
treated for the infection due to the uncertainty of whether or not he had been
exposed to syphilis. An infectious disease specialist was consulted on how MS
should be treated and he recommended penicillin G benzathine 50,000units/kg to
be given intramuscularly. A second consultation confirmed this recommendation,
and the order was recorded and sent to the pharmacy for processing. A dose of
1,500,000 units of penicillin G benzathine was dispensed to the nursing unit for
MS. The dose was given IV, and MS died before the entire dose was administered.
After a thorough investigation, over 50 shortcomings in the system were identified
that, if corrected, could have prevented the death of MS. Investigators determined
that the most lethal mistake was the change in the route of administration from IM
to IV, and as a result, the three nurses involved were charged with negligent
homicide. If the tenfold overdose dispensed by a pharmacist had been determined
to be lethal if given IM, the pharmacist would also have been charged with
negligent homicide.
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Even though obvious errors occurred, a system should be designed in such a
way to recognize these mistakes before administration. The nurses involved
included a nurse practitioner that mistakenly thought it was within her job
description to be able to change the route of administration if it was in the best
interest of the patient. However, she failed to check with a pharmacist or
physician before doing so. She did check a reference book, which did not
specifically mention penicillin G benzathine with respect to IV administration.
Since penicillin G can be administered IV, it was interpreted that benzathine
was a trade name and it was assumed to be the same thing.
The nurses also had not been properly educated about not administering any
cloudy IV fluids (with the exception of fat emulsions). The appearance of the
injection should have prompted them to check with a pharmacist before
administering the medication intravenously. A computer system that detects
high doses in pediatric patients would have been able to catch the high dose
that was dispensed, or at least let the pharmacist know that this dose would
require five injections to the infant. Finally, simply adding "For IM Use Only" on
the pharmacy label would have ended any discussion of changing the route of
administration.
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WHAT YOU CAN DO
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A safety culture demands that systems and process be designed to
eliminate the likelihood of error. Systems must be examined, evaluated
and simplified. Too often they have "evolved" and make little sense in
today's practice environment. In standardizing processes,
simplification and reduction of steps, elimination of transcription,
reduction in handoffs within the process, and the use of preprinted
orders are essential. Reliance on memory should be minimized and
access to supportive information resources increased and
encouraged. Standards, guidelines and protocols must be developed,
and more importantly, adopted for widespread use. All too often, our
healthcare culture is simultaneously over-accepting of the likelihood of
errors occurring, and unforgiving of those in line for the blame. Each of
us bears responsibility and should be accountable for ensuring safety
in the system.
PROCURING, STORING AND
PACKAGING MEDICATIONS
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Separate or secure high-risk or hazardous substances.
Evaluate location of medication stock and inventory methods. Place
ophthalmic, oral, inhalational, injectable and other distinct product
types in specific areas within the pharmacy.
Ensure that expiration dates are checked routinely.
Separate look-alike and sound-alike medications and provide
redundant labels and warnings as reminders.
Evaluate product labeling (e.g. font size, clutter, color) for products
purchased, dispensed and repackaged in order to assure that the user
can easily read information.
Determine standards for dosages and concentrations of products
purchased and provided to patients in order to minimize variation and
the potential for error.
Report and identify product and packaging problems to the supplier.
DISPENSING PROCESS/WORK AREA
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Use reminders and redundancy in the prescription
checking and labeling process (e.g. standardized
labeling requirements).
Assure consistent method for final checks of product;
consider routine use of two-person check for any
dispensed prescription.
Provide adequate references for use by staff and
patients and assure that these are updated.
Identify opportunities to reduce distractions in the
department (e.g. provide adequate space, reduce
potential for unnecessary traffic and interruptions).
PATIENT EDUCATION
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Review prescription use with patient as a component
of the final check.
Ensure patient receives counseling regarding the
safe and effective use of each prescribed
medication.
Encourage patients to ask questions.
Assess patient's level of understanding of medication
information provided. Confirm what information the
prescriber presented and identify gaps and
opportunities for reinforcement.