Transcript Medical Errors in Clinical Care.

PROF. GOVIND MOHAN
Department of Pharmacology
GLA UNIVERSITY
Institute of Pharmacy, Mathura
WHY MEDICATION ERRORS?
• HUMAN BEINGS WILL ALWAYS MAKE ERRORS
• ERRORS ARE COMMON IN MEDICINE, KILLING TENS OF
THOUSANDS
• WE
BEGIN
TO
KNOW
SOMETHING
ABOUT
THE
EPIDEMIOLOGY OF ERROR, BUT WE NEED TO KNOW MUCH
MORE
• NAMING, BLAMING AND SHAMING HAVE NO REMEDIAL
VALUE.
Continued….
WHY MEDICATION ERRORS?
• WE NEED TO DESIGN HEALTH CARE SYSTEMS THAT
PUT SAFETY FIRST (FIRST, DO NO HARM)
• WE KNOW A LOT ABOUT HOW TO DO THAT
• IT’S A LONG, NEVER ENDING JOB
PATIENT
DRUG
INTAKE
DRUG
DOCTOR
INDUSTRY
PRESCRI-
CAUSING
AGENTS OF
MEDICATION
ERROR
PHARMACIST
DISPENSING
PTION
NURSE ADM.
OF DRUG
Continued….
CAUSING AGENTS
DRUG INDUSTRY:
• MISTAKES CAN HAPPEN IN THE MANUFACTURE OF DRUGS
(eg. WRONG EXCIPIENTS).
• PROPER STORAGE PROCEDURES NOT OBSERVED, MAKING
THE DRUGS USELESS eg. USING EXPIRED TETRACYCLINE
HAS BEEN KNOWN TO CAUSE FANCONI’S SYNDROME.
• FAILURE
TO
PROVIDE
CORRECT
PRESCRIBING
INFORMATION: 10mg/Kg 6 HOURLY, WHICH IS THE
Continued….
DRUG INDUSTRY
WRONG
INTERPRETATION,
OR
10mg/Kg/Day
TO
BE
DIVIDED EVERY 6 HOURS, WHICH IS CORRECT.
• FAILURE TO DO POST-MARKETING SURVEILLANCE BY
MANUFACTURERS, AND IF DONE, NOT COMMUNICATING
THESE DATA IN THEIR PACKAGE INSERT.
• MISLEADING HEALTH AND TREATMENT CLAIMS BY
INDUSTRY.
Continued….
DOCTOR PRESCRIPTION
• WRONG ROUTE OF ADMINISTRATION .
• PRESCRIBING THE WRONG FORMULATION (eg. USING
SLOW RELEASE DRUGS INADVERTENTLY WHEN THE
DOCTOR MEANT ORDINARY TABLETS).
• INCORRECT DURATION OF TREATMENT .
• PRESCRIBING WRONGLY FOR A GIVEN INDIVIDUAL eg.
ALLERGY etc.
Continue….
DOCTOR PRESCRIPTION
• PRESCRIBING THE WRONG DRUG.
• WRITING ILLEGIBLY.
• CONFUSING
NAME OF ONE DRUG WITH
ANOTHER.
• PRESCRIBING OR WRITING THE WRONG DOSE.
Continued….
DOCTOR PRESCRIPTION
• WRONG IDENTITY OF THE PATIENT.
• FAILING TO ACCOUNT FOR PRE-EXISTING DISEASE/
CONCURRENT THERAPY.
• PRESCRIBING
WITH
INADEQUATE
OR
INCORRECT
INSTRUCTIONS.
• PRESCRIBING WITHOUT INFORMED CONSENT OF THE
PATIENT
• OFF-LABEL USE OF DRUGS.
PHARMACISTS DISPENSING
• DISPENSING ERRORS viz. GIVING 250 mg/5ml
PARACETAMOL INSTEAD OF THE PRESCRIBED 125
mg/5m UNINTENTIONALLY.
• MISINTERPRETING DOCTOR’S PRESCRIPTION AND
FAILURE TO CONFIRM WITH THE DOCTOR.
• FAILURE TO PROVIDE ADVICE TO PATIENTS eg.
NO
EXPIRY DATE ON STRIPS, INFORMATION
LEAFLETS ARE NOT PROVIDED.
NURSES ADMINISTRATION
OF DRUG
• ERRORS IN TAKING AND GIVING MEDICINES.
• WRONG DRUG.
• CORRECT
DRUG,
INCORRECT
DOSE/DILUTION/
FORMULATION.
• ENTRAINING
AIR
PARTICLES
OR
OTHER
CONTAMINANTS WITH THE DRUG SPECIALLY
PARENTERAL ADMINISTRATION.
IN
Continued….
NURSES ADMINISTRATION
OF DRUGS
• ERROR IN ADMINISTRATION (INTERCHANGING IV, IM,
INTRATHECAL, ORAL, SUBLINGUAL ROUTE).
• GIVING A DRUG OUTSIDE OR AGAINST CURRENTLY
ACCEPTED PRACTICE (OFF-LABEL USAGE).
• WRONG ROUTE, WRONG SITE, WRONG RATE AND
WRONG PATIENT.
WHICH PATIENTS ARE MOST
AT RISK?
• THOSE UNDERGOING CARDIOTHORACIC SURGERY,
VASCULAR SURGERY, OR NEUROSURGERY
• THOSE WITH COMPLEX CONDITIONS
• THOSE IN THE EMERGENCY ROOM
• THOSE LOOKED AFTER BY INEXPERIENCED DOCTORS
• OLDER PATIENTS
PATIENT DRUG INTAKE
• MISUNDERSTADING MEDICATION INSTRUCTIONS.
• POOR
PATIENT
COMPLIANCE,
NOT
COMPLETING
DOSAGE REGIMEN.
• DRUG
PAROXYSM-
WHEN
A
PATIENT
TAKES
A
MEDICINE BUT LATER BECOMES CONFUSED WHETHER
HE ACTUALLY TOOK IT AND TAKES A SECOND DOSE
ERRONEOUSLYPATIENTS.
NOT
RESTRICTED
TO
GERIATRIC
HOW CAN MINIMISE THE
ERRORS?
• IF IT IS POSSIBLE TO WRITE THE DOSE AS A WHOLE
NUMBER, DO SO.
• IF IT IS IMPOSSIBLE OR MORE CONFUSING TO WRITE THE
DOSE AS A WHOLE NUMBER, ENSURE THAT A ZERO
PRECEDES THE DECIMAL POINT. PLACE THE DECIMAL
POINT PROPERLY.
•
COMMUNICATE CLEARLY. MOBILE PHONES AND SHORT
MESSAGE SENDING (TEXTING) CAN LEAD TO ERRORS.
Continued….
HOW CAN MINIMISE THE
ERRORS?
DOCTORS,
NURSES,
TRANSMITTING
AND
ORDERS
PHARMACISTS,
ON
WHEN
PHONE/MOBILES
,
CLEAR PRONUNCIATION OF MEDICAL TERMS AND
LISTENING CAREFULLY CAN PREVENT MISTAKES OF
SIMILAR
SOUNDING
DRUG
Continued….
HOW CAN MINIMISE THE
ERRORS?
• WRITE
A
PRESCRIPTION
CLEARLY
AND
GIVE
INSTRUCTION TO PATIENTS OR THEIR RESPONSIBLE
COMPANIONS.
DIABETIC
THERE WAS A CASE OF AN OBESE
PATIENT
HYPOGLYCEMIC
BEING
MEDICINE
MANAGED
AND
WITH
ORAL
INSTRUCTED
TO
DECREASE WEIGHT IN A VAGUE MANNER. THE PATIENT
DECIDED TO SKIP BREAKFAST AS A ‘DIET CONTROL’
MEASURE BUT CONTINUE TAKING HER MEDICINE,
LEADING TO SYMPTOMATIC HYPOGLYCEMIA. Continued….
HOW CAN MINIMISE THE
ERRORS?
• PRESCRIPTION SHOULD HAVE ALL THE ESSENTIAL
INFORMATION LIKE DOSAGE STRENGTH, THE NUMBER
OF TABLETS, FREQUENCY OF ADMINISTRATION, ROUTE.
• BE
CONSERVATIVE.
PRESCRIBE
ONLY
WHEN
ABSOLUTELY NEEDED. DON’T SATISFY THE WHIMS OF
PATIENTS
WHO
REQUEST
ANTIBIOTICS
TO
TREAT
COMMON COLDS.
• KNOW YOUR PATIENT’S CONDITIONS WELL BEFORE
PRESCRIBING DRUGS.
Continued….
HOW CAN MINIMISE THE
ERRORS?
• PRESCRIBE A MEDICINE WHICH YOU ARE THOROUGHLY
FAMILIAR
WITH
(ADVERSE
EFFECTS,
CONTRAINDICATION, WARNINGS) P-drug concept. DON’T
BE TEMPTED TO PRESCRIBE NEW DRUGS PROMOTED
AGGRESSIVELY BY DRUG COMPANIES.
•
AVOID OVER –PRESCRIBING; THIS IS COSTLY & CAN
LEAD TO ACCIDENTAL OVERDOSE.
Continued….
HOW CAN MINIMISE THE
ERRORS?
• AVOID
POLYPHARMACY.
ALTHOUGH
NOT
ALL
POLYPHARMACY IS BAD WHEN THESE MEDICINES ARE
ACTUALLY NEEDED, BE ATTENTIVE TO THOSE WITH
POTENTIAL FOR HARMFUL INTERACTIONS & BE WARRY
OF DRUG-DRUG INTERACTIONS.
• SPEND TIME TO EDUCATE A PATIENT ABOUT THE DRUGWHEN TO TAKE IT, WHEN TO STOP, WHAT TO EXPECT (eg.
CHANGE IN COLOUR OF URINE?) HOW TO RECOGNIZE
DRUG INTERACTIONS & STORAGE.
Continued….
HOW CAN MINIMISE THE
ERRORS?
• SOME DRUGS WHEN TAKE FOR A LONG TIME,
SHOULD
NOT
BE
ANTICONVULSANTS,
STOPPED
ABRUPTLY
STEROIDS,
(E.G.
SEDATIVE
HYPNOTICS).
• SOME DRUGS WHEN TAKEN FOR LONG-TERM, MAY
LEAD TO DRUG DEPENDENCE AND ABUSE.
Continued….
HOW CAN MINIMISE THE
ERRORS?
• PAY SERIOUS ATTENTION TO THE PATIENT’S HISTORY,
SUCH AS RECORDS OF HYPERSENSITIVITY, ALLERGIES,
IDIOSYNCRASIES OR MEDICAL CONDITIONS THAT ARE
CONSIDERED CONTRAINDICATIONS TO DRUG.
PRACTICAL TIPS…..
• D/C- AS USED IN HOSPITALS CAN MEAN DISCHARGE,
DISCONTINUE OR DILATATION AND CURETTAGE.
• AU VS OU- BECAUSE OF SPELLING ERRORS, CAN
CONFUSE BOTH EARS WITH BOTH EYES.
• DPT VS dpt- A COCKTAIL DRUG PREPARATION USED IN
HOSPITALS KNOWN AS DEMEROL, PHENERGAN AND
THORAZINE
CAN
BE
CONFUSED
WITH
PEDIATRIC
VACCINES CALLED DIPHTHERIA, PERTUSSIS, & TETANUS.
Continued….
PRACTICAL TIPS…..
• HCL vs KCL- AGAIN H and K CAN BE MISREAD & INSTEAD
OF HYDROCHLORIC ACID, POTASSIUM CHLORIDE IS USED.
• Per os vs left eye-os IS SOMETIMES USED IN HOSPITAL
CHARTS TO MEAN OPENING, BY MOUTH OR BY TUBE AND
CAN ALSO MEAN THE LEFT EYE.
• QD vs QID- ONCE A DAY MAY BE CONFUSED WITH FOUR
TIME A DAY.
• QN vs EVERY HOUR qh- AS LETTER N and H CAN BE
MISREAD, EVERY NIGHT IS MISTAKEN AS EVERY HOUR,
Continued….
PRACTICAL TIPS…..
• QOD vs DAILY- THIS IS PARTICULARLY CONFUSING WHEN
DOCTORS
MAKE
ABBREVIATIONS
MISINTERPRETING
EVERY OTHER DAY, OR ONCE EVERY DAY.
• SC vs SL- C FOR CUTANEOUS CAN BE MISTAKEN AS L FOR
SUBLINGUAL.
• IU vs IV- INTERNATIONAL UNITS AS OPPOSED TO
INTRAVENOUS, FOR INSTANCE, INSULIN EXPRESSED IN
UNITS
TO
BE
GIVEN
SUBCUTANEOUSLY
ERRONEOUSLY GIVEN AS INTRAVENOUS BOLUS.
MAY
BE
CONCLUSION
• MEDICATION
ERRORS
CAN
HAPPEN
UNINTENTIONALLY. HEALTH PROFESSIONALS SHOULS
BE VIGILANT ON FINDING WAYS TO PREVENT THESE
ERRORS. ONE WAY IS TO STRENGTHEN EDUCATION
AND SURVEILLANCE SYSTEMS WITHIN THE ADR
REPORTING
CONTEXT.
THE
ROLE
OF
PHARMACOVIGILANCE CENTERS CAN BE EXPANDED
TO ADDRESS PROBLEMS THAT OCCUR IN THE CLINICAL
Continued….
CONCLUSION
SETTING. EVERY HEALTH PROFESSIONAL INVOLVE IN
THE THERAPEUTIC CHAIN SHOULD ALWAYS QUESTION
THE DECISIONS MADE BY THE ONES BEFORE THEM
(NURSES
AND
PHARMACISTS
QUESTION
THE
PRESCRIBER ON MEDICATIONS AS PRESCRIBED ETC.)
• IT WOULD BE SERIOUS TO HEAR THIS FROM OUR
PATIENT: “DOCTOR, I PREFER THE DISEASE TO THE SIDE
EFFECTS OF THE MEDICINES YOU GAVE.”