Transcript Pharmacy Technician*s Course. LaGuardia Community College

Medication Safety
 A medication error is a drug error that may or may not
reach the patient
 It is usually preventable
 It is usually unintentional
 May or May not cause harm
 A medication error that causes death is called a
sentinel event by the Joint Commission
 When a sentinel event occurs the institution is
required to perform a root cause analysis
Type of Medication Errors
 Prescribing Errors
 Involves wrong dose, illegible sigs, wrong frequencies
 Incorrectly transcribing verbal orders from MD
 Dispensing Errors
 Results from mistakes made during dispensing
 Physically preparing medications incorrectly (i.e. using 23.4% saline instead
0.9% saline for an IV admixture)
 Transcribing sig instructions incorrectly

i.e. Methothexate 12.5 mg tablet TIW as 12.5 mg TID
 Error in dosing calculations
 Administration Errors
 Involves nursing
 Incorrect route of administration
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Giving KCL 40 meq IVP instead of KCL 40 meq IVPB over 60 minutes (FATAL)
Giving Vincristine intrathecally instead of intravenously (Fatal)
Giving Penicillin G Benzathine IV instead of IM (can be fatal)
 Causes of Medication Errors
 Performance problems
 Procedure(s) not followed
 Knowledge deficits
 Pharmacists/Pharmacy Technicians that may be
intoxicated by alcohol or drugs
 Social or Family problems
 Noise level at work
 Distractions
Medication Error Reduction Strategies
 Joint Commission “Do not use” list
 ISMP (Institute for Safe Medication Practices) error
prone do not use list
 See Lesson 3 “Medical and Pharmacy Terminology”
 Also see
www.ismp.org/tools/errorproneabbreviations.pdf
 ISMP also publishes a list of confused drug names

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Example concludes Celebrex-Celexa
List can be found at
www.ismp.org/tools/confuseddrugnames.pdf
 Tall Man Lettering
 Tall Man lettering is a strategy implemented by healthcare institutions
in the US under the advise of the Joint Commission , FDA and ISMP
 Involves drug names that can be confused with one and other, see ISMP
confused name’s list
 Drugs with similar sounding names or spelling are called LASA drugsLook Alike Sound Alike drugs
 Tall man lettering involves the use of mixed case lettering to
distinguish between these drugs
 Examples:

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buPROPion VS busPIRone
glyBURide VS glipiZIDE
hydrALAZINE VS hydrOXYzine
 Tall man strategies involves: labeling of these medications, ADC
cabinet display, separating these drugs on pharmacy shelves
 High Alert Medications
 Medications that when used in error can result in
serious patient harm including death
 ISMP has collected a list of such drugs
Category
Examples
Concentrated electrolytes
KCL 2 meq/ml, Calcium
chloride 10% , 3% saline,
23.4% saline
Narcotic Opiates
Morphine, Hydromorphone
Anticoagulants
Heparin, Warfarin
NMB
Succinylcholine,
Rocuronium
Hypoglycemics
Insulin, oral drugs
(glipizide)
Chemotherapy Drugs
Methothexate, Doxorubicin
 High Alert Medication Strategies
 US hospitals and healthcare institutions have published
their own lists that mirrors the ISMP list with some
additions.
 Strategies include:
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Specialized color code labeling for these medications
Segregating the medications in the pharmacy inventory
Restricting access to these drugs in the ADC (non
overrideable)
Specialized alerts in the CPOE and the pharmacy systems
Use of standardized preparations of these drugs
 i.e. Heparin USP 25,000 units/250 ml D5W
 Do Not Crush List
 ISMP publishes a do not crush list
 These drugs should never be crushed
 Typically patients that can’t swallow or have feeding tubes, NG tubes and PEG tubes
have their oral dose forms crushed and administer in about 30 ml of liquid
 Crushing some drugs alters their time course of activity, stability, or expose potential
harm to pharmacy personnel
 Drugs that are long acting
 Effexor XR, Cardizem CD, Detrol LA, KDUR, Paxil CR, Seroquel XR
 Drugs that are enteric coated
 Ecotrin
 Depakote
 Nexium
 Powerful GI irritant
 Actonel®
 Teratogenic (exposure to female pharmacy personnel)
 Isotretinoin

Sublingual Dose Forms

Nitroglycerin
 www.ismp.org/Tools/donotcrush.pdf
Medication Reconciliation
 Medication Reconciliation (MedRecon)
 Required by Joint Commission in accredited healthcare institutions
 Designed to help prevent medication errors due to duplications,
drug interactions and omissions
 The process of medication review that is driven by the prescriber
primarily
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During Triage in the ER, a primary list of medications, OTC and herbals
that patient is taking is to be generated (along with doses and
indications) along with admission orders
During each transition of care (i.e. ER to inpatient unit, inpatient unit to
critical care (ICU)) a review of this list is mandatory along with current
inpatient medication list. Based on this, meds should be discontinued,
maintained or changed with Transfer orders
Upon Discharge, the primary list is reviewed and a discharge medication
list given to the patient explaining any changes to the patient. Discharge
medication list is also to be provide to the patient’s primary care
provider to update the patient’s care
How to report med errors and
adverse drug events
 FDA Medwatch
 ISMP MERP database
 Institute of Medicine (IOM)
 TJC (Joint commission)
 USP Medmarx
 FDA and CDC VAERS system for vaccines
 FAERS is a database that contains information on med
errors and adverse reaction
Pharmacy Technician Role in Error
Prevention
 Question illegible handwriting on written
prescriptions
 Always keep Rx and labeling in mind when filling Rx
 Carefully key in data in pharmacy system
 Ask patient about OTC and herbal medications
Handling of Hazardous Drugs
 OSHA establishes rule
 Hazardous Materials are defined according to their
corrosivity, toxicity, ignitability and chemical reactivity
 Establishes four class of such material. Pharmacy is
concerned with U and P listed chemicals
 U and P must be in containers clearly labeled as such
 Examples of P listed drugs: warfarin, nicotine, nitroglycerin,
physostigmine
 Examples of U listed drugs: mercury, chloral hydrate,
chlorambucil, lindane, phenol, mitomycin, most chemo
agents
 Vendors remove these chemicals from the pharmacy