Transcript Common Dispensing Errors Experienced in Clinical Settings

Common Dispensing
Errors Experienced in
Clinical Settings
Dr. CHENG Chi Man
Murphy’s Law
“Things will go wrong in any
given situation, if you give them
a chance.”
(Steps that can go wrong will go
wrong)
The Person and Systems Approaches
to system error
Reaction to error
(The Person Approach)
• Poster campaigns
• Procedure review
• Disciplinary action
• Threat of litigation
• Retraining
• Naming, blaming and shaming
Reaction to error
(The Systems Approach)
• Error is generalized rather than isolated
• System is reviewed to limit the incidence
of error
• System is reviewed so that if an error
occurs its damaging effects are minimized
• Human
errors cannot be
eliminated totally.
• Medication
errors cause
serious consequences.
On 2/5/2007, WHO launched "Nine patient
safety solutions" to help reduce the toll of
health care-related harm affecting millions
of patients worldwide.
► Look-alike,
sound-alike medication names;
► patient identification;
► communication during patient hand-overs;
► performance
of correct procedure at correct
body site;
► control of concentrated electrolyte solutions;
► assuring medication accuracy at transitions
in care;
► avoiding catheter and tubing
misconnections;
► single use of injection devices; and
► improved hand hygiene to prevent health
care-associated infection.
Medical Mishaps occur in
all health care settings.
•
In the United States, it is estimated that
7,000 deaths each year are caused by
medication errors.
•
In Australia, hospitals show that about 1%
of all admissions suffered adverse event
as a result of medication error.
Medication errors include
errors that happen during:
•Prescribing
•Dispensing
•Administering
Dispensing Errors
Of 1,000 consecutive claims reported to the
Medical Protection Society from 1st July
1996, 193 (19.3%) were associated with
medication and prescribing.
Medication errors causes
serious consequences to
•
•
•
Patients (physical harm; death)
Doctors (reputation; psychological harm;
liability in tort; professional misconduct;
criminal liability)
The Medical Profession (trust; relationship
between doctors and patients)
Source: Apple Daily (A17) 09-06-2005
Dispensing Right
In 2005, the Task Force on Separation of
Prescribing from Dispensing was set up by the
pharmacists.
Recently, the “Separation of Prescribing from
Dispensing Alliance (SPDA)” (爭取醫藥分家大聯盟)
has been formed by the Pharmaceutical Society of
Hong Kong (PSHK), the Practising Pharmacists
Association of Hong Kong (PPAHK) and the Society
of Hospital Pharmacists of Hong Kong (SHPHK)
WE CAN minimize
dispensing errors.
• correct attitude
• knowing how
• doing so
• keeping it up
Good Dispensing
Practice Manual
(July 2005)
by the Task Force on Drug Dispensing
of the Hong Kong Medical Association
The Hong Kong
Medical Association
CME Bulletin
Oct 2006
Why do dispensing errors
happen?
How to
prevent/minimize
dispensing errors?
Prof. David Todd
• How to make a diagnosis?
• First you need to think of that
particular diagnosis.
Alcohol and
Bricanyl
“Look-alike” drugs
•
Look-alike packaging
(both bulk bottles and unit-dose packages)
Flagyl (metronidazole)
Glucophage (metformin)
Delivery from
different orders of
different medicines /
date / companies
Errors from
drug
companies
Errors at
delivery
team
Several orders
at different
date / time
Placement of
order for
different medicines /
dosages
at one time
Omissions
Additions
Wrong
placement
of order
RECEIVING
Wrong
stock
checking
Placing
oral drugs
and drugs for
external use
together
Pre-packing
Fancy names
Generic names
Trade names
Placing
similar
drugs
together
Different
dosages
Change to
smaller
container
Wrong
Similar
container names
Wrong
label
SHELFING
&
STORAGE
Expiry
date
Similar
appearances
Mixing up
of records
Wrong
patient
Abbreviations
Wrong
prescription
Similar
appearances
Lack of
knowledge
Wrong
label
Similar
names
Words
difficult
to read
Wrong
record
TRANSCRIPTION
Ambiguity
Wrong
dosages
Wrong
label
Wrong
quantity
External /
internal
medicine
Wrong
patients
Omission
Several
patients’
medications
at one time
Wrong
dosages
DISPENSING
Wrong
Addition
instructions
Wrong
strength
We have the
responsibility to
ensure patient
safety.
How to prevent
dispensing errors?
• Removing the hazard
• Alerting staff to imminent error
• Preventing completion of hazardous
action
• Minimizing the consequences of error
Removing the hazard (1)
• Check medication by doctor after
receiving from drug company
• Supervise and check by another person
when changing from large container to
smaller container
• Write the name of the medication clearly
on all containers
Removing the hazard (2)
• Make sure that the labels / lids / covers of
the containers will not be mixed up, and
check this regularly
• Do not give fancy names or similar names
to medication
• Make sure assistants know both the
generic and brand name of each
medication, and provide a list where they
can confirm
Removing the hazard (3)
• Do not order medications which look too
similar
• Do not put medications which look similar
together
• Use more individually packed medications
Removing the hazard (4)
• Before pre-packing, have another person to
check the medication from the large
container, make sure that each pack is
clearly and correctly labelled. Containers of
pre-packed medications should be labelled
clearly
• Shelf long term medications (esp. dangerous
ones: DM, HT, psychotrophic, NSAID)
separate with short term medications
Alerting staff to
imminent error
• Hazard warnings and signs, e.g. Attach tags
to containers of medications which are used
in daily or BD dosage instead of more
frequent dosing
• Warning messages in electronic prescribing
systems
• Warning labels on potentially hazardous
drugs, e.g. diabetic medications, potassium,
penicillins
We need to pay attention to special
patient groups where medication errors
can occur more easily
• Patients with drug allergy
• Patients with chronic illness
• Repeat prescription
• Children
We need to pay attention to special
groups of medicine where medication
errors can cause more serious
consequences
• Medicine with narrow margin of safety
• Long term medication
• Medications which need dilution or
compounding
• Medicine for external use only
Education & Training
Certificate Course
for Clinic Nurses
$960
Federation of Medical
(6 Sessions) Societies of Hong Kong
Understanding Drug $6 000
Therapy and
(35 hours)
Management
$200
護理人員醫藥基礎認識
(16 hours)
$190
診所醫護人員配藥技巧
(15 hours)
Open University of Hong
Kong & Hong Kong
Doctors Union
Skills Upgrading Scheme,
Education and Manpower
Bureau
Skills Upgrading Scheme,
Education and Manpower
Bureau
Preventing completion
of hazardous action
Checking and
Double Checking
A study of more than 1 million dispensed
items in British hospital identified 178 errors
(0.018%).
The error rate was 0.01% when the
dispensing of pharmacists and technicians
was double-checked,
compared with 0.035% when there was no
double-check.
Spencer MG. A multicentre study of dispensing errors
in British Hospital. Int. J. Pharm Pract 1993; 2: 142-146
The “Swiss Cheese Model”
of error prevention
The “Swiss Cheese Model”
of error prevention
The more layers of defence there are and
the lower the likelihood of holes in those
defences opening up, the lower the risk of a
damaging error or accident occurring.
Preventing completion
of hazardous action (1)
Checking and double checking:
• Checked by the one who prepared the
medications, then by the doctor, and then
by the one who give the medications to
the patient
Preventing completion
of hazardous action (2)
Checking and double checking:
• Date
• Name of patient
• Number of types of medication
• Type (make sure all parties can recognise
each medication. If in doubt, open a new
bottle for confirmation, or contact the
drug company)
Preventing completion
of hazardous action (3)
• Dosage (how many tabs each time? How
much syrup each time?)
• Frequency of dosing
• Number of tablets/volume of syrup in
each pack
• Route of adminstration
• Container
• Drug allergy
Preventing completion
of hazardous action (4)
The use of Information Technology
• e.g. electronic systems which prevent
prescribing of a penicillin to a patient with
known allergy
Minimizing the
consequences of error
• Encourage staff to report immediately if
anything goes wrong
• Communicate with patients and allow
channels for enquiry and complaint
Vanilla ice-cream = Car problems?
Even insane looking problems are
sometimes real
General Motors received a complaint.
A man could not restart his car engine
everytime after he bought a vanilla icecream, but not other favors.
An engineer looked into the matter and found
that this was really the case.
It took less time to buy a vanilla ice-cream
than other favors.
Eventually it was found out that the vapor
lock of the model had some defects.
So, it might be worth spending some time on
seemingly insane complaints !
My Own Story
A patient called after seeing me for URTI.
He complaint of nausea and headache after
taking medication for one time.
I reviewed the record and found nothing
wrong with the medications.
Dispensing Error Incident Report