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Medication Errors

Course Name: Hospital Pharmacy Course code: PHC222 Date: December 2011 (DK1)

At the end of this lecture you will be able to:


define the term medication errors identify medication error severity levels flow chart of medication errors describe different types of medication errors identify causes, risk factors that contribute to medication errors suggest ways to prevent medication errors

ME is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer.
Any error occurring in the medication-use process.

Writing a medication order, Interpreting & transcribing medication orders, preparing & dispensing medications or administration of medicines.

The main goal of drug therapy is to achieve a defined therapeutic outcomes that improves a pts QOL. However, there are inherent risks (known & unknown), associated with therapeutic use of drug administration. Problems & sources of ME are multidisciplinary & multifactorial. May be committed by both experience & inexperience staff.

Many ME are probably undetected.

Doses omitted Wrong dose Unprescribed drug given Wrong dosage form given Wrong route of administration Wrong rate of administration

Yes Yes Yes Yes


Yes

Yes

Wrong time of administration


time of day in relation to food etc....

Yes

Using unstable/expired drug Wrong administration technique Incorrect reconstitution Extra dose given

Yes
Yes

Yes

Prescriber writes the Rx Pharmacy receives, screen & interpret the Rx from ward Drugs put into medication drawer/bin of individual pt by pharmacy assistant

Trolley return back to satellite

Counterchecking med filled before delivery Trolley with med bins send to ward

Nurse administers drug to pt

Patient in ward

Point for prescribing error


Point for dispensing error

Point for error by nurses

Point for error by patient

Prescribing errors

occurs at the time a prescriber orders a drug for a specific patients Errors may include, incorrect drug selection (based on indications, C/I, known allergies, existing therapy), dose, dosage form, quantity, route, concentration, rate of administration, or instruction for use. Rx that are filled incorrectly due to illegible handwriting would be considered prescribing error.

E.g.: Rx for amoxicillin 250mgPO TID may be appropriate to treat a middle ear infection in a 5-year-old child but would be too high a dose for a 12-month-old infant.

Omission errors

Failure to administer an ordered dose to a patient in a hospital, nursing home, or other facility before the next scheduled dose. An Omission error occurs when the dose is completely omitted as opposed to administered late.
If a dose is ordered to be held for medical reasons, it is not considered an error. For e.g. pt cannot take anything by mouth prior to a procedure, or when health care provider are waiting for drug levels results to be reported. Also if a pt refuses to take medication is not consider as an omission error.

Wrong time error

Administration of medication outside a predefined time interval from its scheduled time.
Timing of administration is critical to the effectiveness of some medications such as antibiotics to maintain adequate drug serum concentration. In certain cases wrong time errors are unavoidable such as if the pt is away from the ward for a test or the medication is not available at the time it is due.

Unauthorized drug errors

Administration of medication to a pt without proper authorization by the prescriber. It might occur if a med for one pt was mistakenly given to another pt, or if a nurse gave a med without physician order. Refilling a prescription that has not refills remaining without authorization from the physician is another example of unauthorized drug errors.

Administration of medications outside the established guidelines is another example of unauthorized drug errors.

Improper dose error

Administration to pt of a dose that is more or less than the prescribed dose. This type of error may occur if there is a delay or absence in documenting an administered dose that results in an additional dose being administered. Inaccurate measurement of an oral liquid is also an improper dose error.

Wrong dosage form error

Doses administered or dispensed in a different form from that ordered by the prescriber.

In certain cases changes in dosage form are acceptable according to the pts need and thus not considered as wrong dosage form errors. For e.g. dispensing a liquid preparation without a specific prescription to a pt who has difficulty swallowing tablets.

Wrong drug-preparation error

Drug product incorrectly formulated or manipulated before administration. Incorrect dilution or reconstitution, mixing incompatible & inadequate product packaging. For e.g. using bacteriostatic saline for injection instead of sterile water for injection to reconstitute a lyophilized powder for injection

Wrong administration-technique error

Doses that are administered using an inappropriate procedure or incorrect technique. For e.g. wrong route & site of administration, wrong rate etc.

Deteriorated drug error

Administration of a drug that expired or for which the physical or chemical dosage form integrity has been compromised. Drugs that have passed their expiration date may have lost their potency and may be less effective or ineffective.

Monitoring error

Monitoring errors result from inadequate drug therapy review.


Failure to use appropriate clinical or laboratory data for adequate assessment of pt response to prescribed therapy. For e.g. failure to respond to the levels of phenytoin above therapeutic range or failure to monitor blood pressure after administering a blood lowering antihypertensive medication.

Compliance error

Inappropriate pt behavior regarding adherence to a prescribed regimen. These errors may be detected when a pt requests refills of prescriptions at an unreasonable intervals (too long or too soon before a refill is due) without a reasonable explanation.

Ambiguous strength designation on labels or in packaging.


Drug product nomenclature look-alike, sound-alike names.(Amrinone(Inocor) Vs amiodarone (Cordarone) Equipment failure or malfunction.

Illegible handwriting (Aredia (pamidronate) Vs Adria (doxorubicin)


Improper transcription Inaccurate dosage calculation (calculation error, decimal points and zeros) Inadequately trained personnel Inappropriate abbreviations used in prescribing (U as an abb of units, QD instead of daily as it could be read as QID) Labeling error Excessive workload Poor work environment (light, noise, poorely design work place etc)

Work shift

Inexperienced & inadequately trained staff


no / quantity of medicines per patients (Polypharmacy)

Environment factors lighting, noise, interruptions


Staff workload & fatigue.

Poor communication among healthcare professionals

Type of distribution system Unit of dose system is preferred Improper drug storage Extent of measurement / calculation required

Confusing drug product nomenclature


Poor handwriting

Verbal orders
Lack of policies & procedures

Participate in drug therapy monitoring.


Rx screening, drug use evaluation (DUE) activities.

Stay abreast of current state of knowledge & participate in CE programs & provision of drug info.

Offer prescriber & nurses info & advice about therapeutic drug regimens.
Never assume or guess the intent of confusing ME. Maintain orderliness & cleanliness in work area.

For high risk product, all work should be doublechecked by a 2nd pharmacist to make certain that the drug labeling, packaging, quantity, dose & instructions are accurate.
Review the use of auxiliary labels. Ensure meds are delivered to pt care area in a timely fashion after receipt of med orders. Review med orders-drug name & dosage regimen. Review med that are returned to pharmacy-omitted doses or unauthorized drugs.

Verify of pts understanding about Rx instruction & labeling. Pt counseling service should be offered to high risk pt for ME & adverse drug events.

Maintain sufficient records to enable identification of pts receiving an erroneous products.

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