Transcript medication e

MEDICATION ERRORS
Common Medication Errors
Prediction and Prevention of Medication Errors
PHCL 328
Done by: Nouf Albishi, PharmD candidate
Supervised by: Dr.Ghada Abuhaimed
Outline
• Important Definitions
• Common Medication Errors
• Common causes of medication errors
• Prediction and Prevention of Medication Errors
• Principals for Improved Safety
Definitions
• Adverse drug event (ADE):
• Injuries due to medications and it include ADR and medication errors
that resulted in harm.
• Adverse drug reaction (ADR):
• A response to a drug which is noxious and unintended, and which
occurs at doses normally used in man for prophylaxis, diagnosis, or
therapy. (Non-preventable ADEs)
Definitions
• Medication error defined by the National Coordinating Council for
Medication Error Reporting and Prevention (NCC MERP) as
– "any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the control of
the health care professional, patient, or consumer.
• An error occurs in the medication process (ordering, transcribing,
dispensing, administering, and monitoring).
Where Do Medication Errors
Occur?
Medication use process
Common Medication Errors
1- Patients can be given the wrong drug or dose because of an
error in reading or writing a prescription.
2- Doctors can fail to find out if a patient is allergic to a particular
drug or has a condition that can be worsened by a medication.
3- Different drugs may interact with each other to trigger a
problem.
4- Two drugs with similar side effects can amplify the extent of
that side effect synergistically.
Common causes of medication
errors
1- Incomplete patient information.
2- Unavailable drug information(such as lack of up-to date
warnings).
3- Illegible handwriting.
4- Confusion between drugs with similar names.
5- Inaccurate dosage calculation.
6- Excessive workload.
Common causes of medication
errors
7-Misuse of zeroes and decimal points.
8-Environmental factors, such as lighting, heat, noise, and interruptions,
that can distract health professionals.
9- Similar packaging, labeling or dosage form
Prediction and Prevention of Medication
Errors
A) Predicting look-alike and sound-alike medication
errors:
– Look Alike Medications:
• Refer to names of drugs which due to their spelling, may look similar with
other drug name and/or packaging.
– Sound Alike Medications:
• Refer to the name of drugs which due to their pronunciation, may sound
similar with other drugs name.
Look Alike Medications
Sound Alike Medications
Amantadine Vs. Ranitidine
Clonazepam Vs. Clobazam
How to prevent LASA medications errors ?
• Minimize the use of verbal and telephone orders.
• Carefully read the label each time a medication is accessed and
again prior to administration.
• Check the purpose of the medication on the prescription
• Include both the generic name and the brand name on medication
orders and labels.
• Emphasize drug name differences using methods such as “tall
man” lettering .
• Storing problem medications in separate locations.
Tall man lettering
Prediction and Prevention of Medication
Errors
B) Predicting illegible handwriting & incomplete
information errors :
• Common cause of prescribing errors.
• Delays medication administration.
Illegible Handwriting
15
How to minimize Illegible handwriting errors ?
E-prescribing
• Utilization of electronic prescribing by entering orders on a computer, better known
as Computerized Physician Order Entry (CPOE).
• CPOE systems allow physicians to enter prescription orders into a computer thus
– Eliminating illegible and poorly handwritten prescriptions,
– Ensuring proper terminology and abbreviations,
– Preventing ambiguous orders and omitted information.
Prediction and Prevention of Medication
Errors
C) Predicting errors of misuse of zeroes and decimal
points in a written medication orders:
•
Avoid whenever possible
– Use 500 mg for 0.5 g
– Use 125 mcg for 0.125 mg
• Never leave a decimal point
“naked”
– Haldol .5 mg  Haldol 0.5 mg
• Never use a terminal zero
- Colchicine 1 mg not 1.0 mg
• Space between name and dose
- Inderal40 mg  Inderal 40 mg
Never use a terminal zero
Never leave a decimal point
Prediction and Prevention of Medication
Errors
D) Do Not Use Abbreviations
• Drug names
• “QD” or “OD” for the word daily
• Letter “U” for unit
• “µg” for microgram (use mcg)
• “QOD” for every other day
Do Not Use Abbreviations
• “sc” or “sq” for subcutaneous
• “a/” or “&” for and
• “cc” for cubic centimeter
• “D/C” for discontinue or discharge
Avoiding ambiguous abbreviation
Case
A 62-year-old patient on hemodialysis was treated
for a viral infection with acyclovir. The order was
written as “Acyclovir (unknown dose) with HD”.
The order was misinterpreted as TID (three times
daily). Intravenous acyclovir should be adjusted for
renal impairment and given after hemodialysis once
daily.
The patient received three doses daily during a twoday period, resulting in a rapid mental decline,
delirium, and subsequent death.
USING ABBREVIATIONS
MAY SAVE MINUTES!
PROHIBITING
ABBREVIATIONS MAY
SAVE LIVES!!
OD/QD is the most commonly used Error
Prone (Prohibited) Abbreviation
Drug name abbreviation
Secondary Literature
25
Medication Names Should
be Written in Full
Abbreviations are
NOT Permitted
“U” vs. “Unit”
“U” vs. “Unit”
28
“μg” vs. “mcg” ?
29
Principals for Improved Safety
A) Eliminate the possibility of errors
– Reduce the number of medications on hospital
formulary.
– Reduce the number of concentrations/volume to
the most appropriate ones.
– Minimize the number of medications in the floor
stock.
Principals for Improved Safety
B) Make error visible
- TWO individual independent checking for High
Alert Medications.
Principals for Improved Safety
C) Minimize the consequences of error
- Minimize the size of vial or ampoules in the patient
care area.
Principals for Improved Safety
D) Creation of the Patient-Provider Relationship
–
Patients should understand more about their medications and
take more responsibility for monitoring those medications.
–
Providers should take steps to educate, consult with, and
listen to the patients.
Principals for Improved Safety
E) Electronic Technology
• Bar Coding
– A tool that ensure that the right medication and the right dose
are administered to the right patient.
• Electronic Prescription Record (EPR)
– Pharmacists use the record as a tool to reduce medication
errors by guarding against drug interactions, duplicate therapy
and drug contraindications.
Principals for Improved Safety
• Computerized Physician Order Entry (CPOE)
– Allow physicians to enter prescription orders into a
computer or other device directly
F) Reporting Medication Errors
– Health care professionals and consumers have the
opportunity to report the occurrence of medication errors to
a variety of organizations (SFDA).