Medication Errors

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Medication errors, their types, contributing factors, methods to minimise them and importance of ME reporting are discussed in this presentation.

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Medication Errors:

Medication Errors P.Naina Mohamed Pharmacologist

Introduction:

Introduction The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) definition: “A medication error (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 health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.” Any error in the prescribing, dispensing or administration of a drug whether there are adverse consequences or not. They are the single most preventable cause of patient injury. They can occur at any stage in the drug use process, from prescribing to administration to the patient. They are responsible for about 25% of litigation/medicolegal cases against general practitioners.

Major Causes of Medication Errors:

Major Causes of Medication Errors Institute of Safe Medication Practices’ Major Causes of Medication Errors Missing patient information (allergies, age, weight, pregnancy, etc.) Missing drug information is (outdated references, etc.) Miscommunication of drug order (illegible, incomplete, misheard, etc.) Drug name, label, packaging problem (look/sound alike, faulty drug identification) Drug storage or delivery problem Drug delivery device problem (poor device design, IV administration of oral syringe contents, etc.) Environmental, staffing, workflow (lighting, noise, workload, interruptions, etc.) Lack of staff education Lack of Patient education (Lack on patient consultation, non-compliance) Lack of Physician knowledge (when a drug comes to market that replaces an existing one or several ones, i.e., a combination drug may mean that a person takes it once a week instead of daily)

Other Causes of Medication Errors:

Other Causes of Medication Errors Research has illustrated that there are five errors for every 100 orders. The Institute for Safe Medication Practices (ISMP) reports… 30% of errors are due to deficient drug knowledge 20% are caused by limited patient knowledge 50 % are a result of poor labeling or drug nomenclature Stress/ Fatigue/ Ignorance Personal neglect/ Hesitation Heavy workload Inexperience/ Unfamiliarity with medication New staff/ Insufficient training Complicated order Unfamiliarity with patient’s condition Faulty judgment Faulty communication Failure to monitor closely System flaws

Types of Medication Errors:

Types of Medication Errors Prescribing Errors Dispensing Errors Drug administration Errors Monitoring Errors Compliance Errors

Prescribing Errors :

Prescribing Errors Most common type of medication errors. Account for 80% of all medication mistakes. Use of dangerous abbreviations Majority of the prescribing errors. Many pharmacists and/or nurses, misread the "u" abbreviated for units, for a (0) or a (4) causing a 10-fold overdose or greater. Always use a leading zero (0.4mg) and never use a trailing zero (4.0 mg). Illegible handwriting and verbal orders Prescribing errors. Incorrect drug selection (dose, strength, route, quantity, indication, and contraindications) for a patient Prescribing Errors. A study suggests 4 prescribing errors occurred per 1000 medication orders. Of the errors drug allergies accounted for 12.1%, wrong drug name, dosage form or abbreviation for 11.4% incorrect dosage calculations for 11.1% and incorrect dosage frequency for 10.8%.

Contributing factors for Prescribing Errors:

Contributing factors for Prescribing Errors Inadequate knowledge Calculation errors Uncommon dosage regimen frequencies Complicated dosage regimens Poor patient history taking Use of multiple dosage forms per dose Use of abbreviations Mental slips Lack of adequate resources Different drug formulations available Excessive interruptions while involved in writing prescriptions or orders Illegible handwriting Drug name confusion (Look alike Sound alike) Inappropriate use of decimal points Use of verbal orders.

Methods to Minimise Prescribing Errors:

Methods to Minimise Prescribing Errors Ensuring up-to-date reference sources. Use of computerised physician order entry. Ensuring knowledge of a drug before prescribing. Ensuring an accurate drug history is taken. Printing the drug name and patient details clearly on the prescription Including all details of drug therapy i.e. name of drug, dose, directions, duration of therapy A zero should always precede expression of values <1 e.g 0.1. Ten-fold errors in dose have occurred due to the use of a trailing zero. Avoiding the use of abbreviations e.g. AZT, ISMN, FeSO4, U Being aware of Look alike and sound alike (LASA) products.

Prescribing Errors:

Prescribing Errors Error Reducers for Verbal Orders ♦ Repeat the order to the physician. ♦ Record the order and the time into the patient’s chart as soon as order is received. ♦ Follow-up with a written order, ensuring it is signed and dated according to policy. ♦ Use only in emergency situations. ♦ Never use verbal orders for chemotherapy or high-alert drugs. ♦ Limit who may take verbal orders.

Dispensing Errors:

Dispensing Errors Occur at any stage during the dispensing process (from the receipt of a prescription to the supply of a dispensed product to the patient). Research estimates that 5% of all prescriptions are dispensed improperly. Dispensing errors Reduce patient’s confidence in the pharmacist. Confusion occurs primarily with drugs that have a similar name or appearance. Lasix® (frusemide) and Losec® (omeprazole) Confusion also occurs between amiloride 5mg and amlodipine 5mg tablets.

Contributing factors for Dispensing Errors:

Contributing factors for Dispensing Errors confusing the name of one drug with another. Two or more drugs have a similar appearance or similar name (look-a-like/sound-a-like) Selection of the wrong strength/product. Lack of knowledge on new medicines. Use of outdated and/or incorrect references. Poor dispensing procedures with inadequate checking. Unreasonable workloads. Poor housekeeping standards. Distractions and interruptions. Dispensing unfamiliar products. Dispensing before seeing a written order. The use of computerised labelling Transposition and typing errors (most common causes of dispensing error).

Methods to Minimise Dispensing Errors:

Methods to Minimise Dispensing Errors Ensuring a safe dispensing procedure. Using different brands or separating LASA (Look alike and Sound alike) products. Focusing on the task in hand. keeping interruptions to a minimum. Maintaining workload at a safe and manageable level Being aware of high risk drugs (HAM) e.g. Hypertonic Electrolytes (Potassium chloride, Calcium chloride, Magnesium Sulphate), cytotoxic agents, IV Insulin. Introducing good housekeeping practices.

Administration Errors:

Administration Errors Discrepancy between the drug therapy received by the patient and the drug therapy intended by the prescriber. Administration errors account for 26% to 32% of total medication errors. Types: Omission Error (e.g: lack of stock). Extra Dose Error Wrong dose error Wrong route error (Left eye instead of Right) Wrong rate error Wrong dosage form (Crushing tablets) Wrong time error Wrong administration technique (e.g : Incorrect manipulation of Inhalers). Administration of expired drugs Administration of wrong preparation

Contributing Factors of Administration Errors:

Contributing Factors of Administration Errors Failure to check the patients identity prior to administration. Storage of look-a-like preparations side by side in the drug trolley. Environmental factors such as noise, interruptions and poor lighting while undertaking the drug round. calculation to determine the correct dose. where more than one tablet is required.

Methods to Minimise Administration Errors:

Methods to Minimise Administration Errors Checking patients identity. Having dosage calculations checked independently by another healthcare professional before the drug is administered. Having the prescription, the drug and the patient in the same place so they can be checked against one another. Ensuring that medication is given at the correct time. Minimising interruptions during drug rounds.

Monitoring & Compliance Errors:

Monitoring & Compliance Errors Monitoring Errors: Monitoring errors are caused by… Failure to review a prescribed regimen for appropriateness Failure to use appropriate clinical or laboratory data to assess the patients’ response to prescribed therapy. Compliance Errors: Compliance errors are caused by… Inappropriate patient behavior regarding adherence to a prescribed medication regimen

Ten key elements of medication use :

Ten key elements of medication use The Institute for Safe Medication Practices (ISMP) has identified 10 key elements. Weaknesses in these medication errors. Patient information Drug information Adequate communication Drug packaging, labeling, and nomenclature Medication storage, stock, standardization, and distribution Drug device acquisition, use, and monitoring Environmental factors Staff education and competency Patient education Quality processes and risk management.

Avoiding medication errors:

Avoiding medication errors Perform the “five rights” of medication administration every time— right patient (using two identifiers), right drug, right dosage, right time, and right route. Some experts have expanded this list to include: • right reason for the drug • right documentation • right to refuse medication • right evaluation and monitoring. Be sure to use the safety resources available at your facility. Don’t use workarounds to bypass safety systems. Read back and verifying medication orders given verbally or over the phone. Ask a colleague to doublecheck your medications when giving high-alert drugs Use an oral syringe to administer oral or NG medications Assess patients for drug allergies before giving new medications Be familiar with your facility’s “do not use” list of abbreviations.

Eliminating medication errors:

Eliminating medication errors Computerized physician order entry reduces errors by identifying and alerting physicians to patient allergies or drug interactions, eliminating poorly handwritten prescriptions, and giving decision support regarding standardized dosing regimens. Use of computerized physician order entry and barcodes may reduce errors by up to 50%. Be sure to use the safety practices already in place in your facility. Eliminate distractions while preparing and administering medications. Learn as much as you can about the medications you administer and ways to avoid mistakes.

Preventing Medication Errors:

Preventing Medication Errors Review each medication to determine its necessity Make sure the list of medications is complete Identify the condition for which each medication is prescribed Determine the potential for any drug vs. drug interactions Determine potential for any drug vs. disease interactions Can the drug regimen be simplified? Are there any new, safer drugs available to substitute with current medication? Is it possible to discontinue any medication?

Preventing Medication Errors:

Preventing Medication Errors New medication tips Is the diagnosis correct? Can the condition be treated without medication? Can a lower dosage be used? Could the symptoms be related to another medication? Can one drug be used to treat multiple conditions?

Preventing Medication Errors:

Preventing Medication Errors Inappropriate medication use Don’t try to treat every condition. It is impossible to treat every physical condition Don’t try to treat the side effects of medications Try to have one physician prescribe all medications Make sure all physicians involved in a patients treatment are aware of each other Clearly, the most important preventative measure is to take an active role in the care of your loved one. Making regular, unscheduled visits is suggested. Do not be afraid to ask questions from those who have a role in the dispensing of medications. A clarification may prevent an episode of injury down the road.

Underreporting of medication errors:

Underreporting of medication errors Most important Reasons: Disagreement over the definition of an error Staff’s disability to recognize an error has occurred Staff’s belief that the error does not warrant reporting Staff’s belief that she/he has not committed the error Staff’s embarrassment Staff fear for the reputation on of their service or unit Staff’s fear of punishment/disciplinary actions Degree of reporting effort/ time to complete reports Wrong reporting time Local/unit’s culture Confusing reporting mechanisms, policies, or procedures

Conclusion :

Conclusion Each healthcare professional is responsible for identifying contributing factors to medication errors and using that knowledge to reduce their occurrence. No one in the healthcare profession wants to make a mistake and they want to help people not harm them. Both experienced and inexperienced staff may be responsible for medication errors. Healthcare is changing from a system of blaming to a system that encourages finding the factors that caused the error. A multidisciplinary approach to solve this problem should be promoted. Hospitals should form committees to research all errors and “near misses” in order to make changes to keep patients more safe. All healthcare facilities should have safety systems to prevent errors, test those interventions, and reevaluate if the intervention is successful or not. The safety systems must empower the facility's staff to question orders, treatments, or any situation that seems out of the norm.

Conclusion :

Conclusion Healthcare providers should encourage patients to ask questions as well! Patients must actively participate in their healthcare. Mistakes will still occur. By implementing systems that examine, identify, and find root causes, some errors can be prevented from happening over and over again. Although it is a long and hard process, it is a valuable process that all healthcare facilities, as well as healthcare professionals, need to be involved in! Due to increasing risk of medical litigation means that healthcare professionals cannot ignore a medication error when it occurs .

Help Websites to avoid medication errors :

Help Websites to avoid medication errors The websites below provide accurate information about the consequences of medication errors and ways to avoid such errors. Drugs and lactation database (National Library of Medicine) http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT Epocrates electronic drug resource www.epocrates.com FDA MedWatch www.fda.gov/Safety/MedWatch/default.htm Institute for Safe Medication Practices www.ismp.org MedlinePlus: Drugs, Supplements, and Herbal Information www.nlm.nih.gov/medlineplus/druginformation.html National Coordinating Council for Medication Error Reporting and Prevention www.nccmerp.org

REFERENCES:

REFERENCES http://www.ashp.org/s_ashp/docs/files/MedMis_Gdl_Hosp.pdf http://www.fda.gov/drugs/drugsafety/medicationerrors/default.htm http://jamestodonnell.com/downloads/Ch27-A03753[1].pdf http://ec.europa.eu/public_opinion/archives/ebs/ebs_241_en.pdf http://www.rcn.org.uk/__data/assets/pdf_file/0016/250801/KostasMedication_Errors.pdf http://www.nymc.edu/fammed/medicalerrors.pdf

REFERENCES:

REFERENCES http://francais.bbraun.ch/documents/Knowledge/Content_Wissen_Risikopraevention_Infusionstheraphie_Medication_Error.pdf http://www.ismp.org/pressroom/Patient_Broc.pdf http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf http://www.ahrq.gov/patients-consumers/care-planning/errors/20tips/20tips.pdf

REFERENCES:

REFERENCES http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Duthie.pdf http://www.stjames.ie/GPsHealthcareProfessionals/Newsletters/NMICBulletins/NMICBulletins2001/VOL7-3MEDICATION%20ERRORS.pdf http://jama.jamanetwork.com/collection.aspx?categoryid=5744 http://www.orlandohealth.com/pdf%20folder/patient%20safety.pdf

REFERENCES:

REFERENCES http://www.americannursetoday.com/assets/0/434/436/440/6276/6334/6350/6356/8b8dac76-6061-4521-8b43-d0928ef8de07.pdf http://www.cdcan.us/Health/MedicationsErrorPanel-FULLFINALREPORT.pdf http://www.nlm.nih.gov/medlineplus/medicationerrors.html http://www.nccmerp.org/aboutMedErrors.html http://napra.ca/pages/Practice_Resources/minimizing_medication_errors.aspx

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