Medication Errors
ERROR DEFINITION.
A medication error 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 .
National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP)
MEDICATION ERROR PROBLEM
• An estimated 7000 deaths per year are caused by
medication errors.
• More Americans die of medication errors annually
than from workplace injuries.
• Medication harm have a cost, calculated at as much
as $2 billion annually.
Institute of Medicine. To Err Is Human: Building a Safer Health System. Kohn LT, Corrigan JM,
Donaldson MS, eds. Washington, DC: National Academy Press, 2000.
Second report, Crossing the Quality
Chasm: A New Health System for the 21st
Century.
Three problem categories introduced.
• Misuse
–failures to execute clinical care plans and
procedures properly.
• Overuse
–use of health care resources and procedures in
the absence of evidence.
• Underuse
–failure to employ health practices of proven
benefit.
TYPES OF ERRORS.
A. Wrong drug error.
B. Extra dose error.
C. Omission error.
D. Wrong dose/wrong strength error.
E. Wrong route error.
F. Wrong time error.
G. Wrong dosage form error.
H. Other.
Type of Error Explanation Example
Wrong drug A drug that was not ordered for a for example, a patient accidentally received
error patient was administered. furosemide 40 mg orally.
Extra dose A patient receives more doses of a patient received a medication with
error. a drug than were ordered. breakfast for 5 days instead of 3 days.
Omission drug was not administered as patient was supposed to receive digoxin
error ordered but was skipped. 0.25 mg orally but did not receive the dose.
Wrong dose wrong dose of a medicine or the patient was supposed to receive warfarin .5
or wrong wrong strength is administered mg but received 5 mg instead.
strength error
Wrong route patient receives a dose of a patient was supposed to receive
error medication by a route that was prochlorperazine 10 mg IM but was
not ordered by the physician. administered IV.
Wrong time patient does not receive a dose of hospitalized patient with diabetes is
error medication at the time at which it scheduled to receive insulin immediately
was to be administered. before breakfast but the dose is given 2 hr
after breakfast .
Wrong patient receives a dose of nicotinic acid 500 mg tablets were
dosage form medicine in a dosage form that ordered,Patient instead received nicotinic
error was not intended. acid 500 mg slow- release capsules.
Other Errors that do not fit into any of the other categories.
COMMON ERROR HAZARDS
Dangerous The letter U can easily be patient received 66 units of insulin
abbreviations misinterpreted as a number (e.g. , instead of 6 units.
0 or 4) .
U, IU: unit (s) results in serious harm with “6U” of regular insulin was misread
insulin and heparin as 66.
QD, Q.D,qd, q.d. misinterpreted as “QID” or “qid” resulting in overdoses.
(daily) (four times daily)
Q.O.D, QOD, qod misinterpreted as QID ( four times resulting in overdoses.
(every other day) daily)
Trailing zero When a dose is ordered and Decimal point may be missed and an
followed with a decimal point and overdose can occur .
a zero, such as 2.0 mg . warfarin 2.0 mg may be
misinterpreted as 20 mg
Lack of leading zero drug's dose less than 1 mg. digoxin .25 mg instead of digoxin
dose is written without a leading 0.25 mg.
zero.
MS, abbreviations for morphine sulfate
MgSO4 and magnesium sulfate are quite
similar and can be confused.
confusing symbols, cc. instead of mL. misinterpreted as a 0.
abbreviations.
μg/micrograms mistaken for mg.
HCT for hydrocortisone misinterpreted as hydrochlorothiazide.
Sound-a- like or look-a- Amitriptyline and Cisplatin and carboplatin.
like drug names. aminophylline.
High- risk drugs.
potent drugs have been implicated in many serious/tragic medication errors and have been
called high-risk or high-alert drugs.
Blood-modifying agents heparin and warfarin. Overdose.
results in serious injury or death from
hemorrhaging
Narcotics and sedatives. diazepam 25 mg given CNS depression and respiratory arrest .
intravenously instead
of 2.5 mg.
Neuromuscular succinylcholine and Accidental use before adequate ventilation
paralyzing agents vecuronium. procedures have resulted in respiratory
arrest and death.
Chemotherapy drugs. Associated with immune, neurologic, and clotting
potent adverse effects systems,……………………..Deaths
IDENTIFYING RISK
• Medications are inherently toxic, and there is a risk to
taking them.
• So a treatment risk versus benefit must be assessed.
• Health care professionals can make mistakes.
• Yet, during training they are immersed in an
environment where there is no room for error.
• Examining what happened when an error occurs is
means to develop future prevention strategies.
Latent Conditions…………RCA
This is error that has been defined as beyond the individual.
faulty design, poor maintenance, error in overall management.
Example: an intravenous infusion device not adequately calibrated, not maintained.
Latent Conditions: weakness in a system that does not immediately result
Lack of adequate patient information . in an error but, under the right set of circumstances,
Lack of appropriate communication. can contribute to a mistake.
Lack of medication information For example:
Lack of adequate medication labeling Stocking look-alike or sound-alike drugs next to each
Lack of adequate training or resources other , contributing to a pharmacist incorrectly filling a
prescription.
Inadequate training of employees, contributing to an
error
ROOT CAUSE ANALYSIS (RCA). What happened and why?
a structured process for identifying What were the contributing factors?
direct and indirect factors that Age? Hours worked? Staffing?
contributed to a medication error Workload? Stress? Confusing names? Location on
shelf?
Inadequate information? Communication?
Inadequate equipment?
Workplace atmosphere conducive to
safety?Inadequatet raining of pharmacist or
technician?
Medication errors in pediatrics
The incidence of medication errors are significantly greater than in adults because:
lack of standard dosage.
Calculation errors by the prescriber.
Requiring calculations of commercially available products .
Limited published information.
Lack of familiarity with paediatric dosing guidelines.
use of inappropriate measuring devices.
NATIONAL SAFETY EFFORTS to Prevent ME
1. Improve the accuracy of 2. Improve communication 3. prohibit the use of those
patient identification. among caregivers. abbreviations that are prone
to confusion and
Have two means of identifying misinterpretation.
the patient other than room
number.
4. Develop methods of 5. All medications and 6. Reduce the risk of
identifying and reviewing sound- containers should be infections.
alike and look-alike drugs properly labeled.
7. Comply with all Centers for 8. Thoroughly investigate all 9. Keep accurate patient
Disease Control and Prevention serious adverse events and medication records and
recommendations deaths associated with histories
infection acquired in a
healthcare setting.
10. Ensure that a patient 's medication records are complete and accurate when he or
she is referred or transferred within or between organizations.
JCAHO's National Patient Safety
Prevention of medication errors and
Role of Pharmacist
• Prescription should be read completely and carefully.
• Determine the compatibility of the newly prescribed medication with other
drugs.
• Consider if any significant drug–interactions may exist.
• Consider alternative drug products that can be used.
• Consult with the prescriber to determine best therapeutic alternative.
• The same would apply when patient is allergic to prescribed medication.
• if it appears that an error has been made, consult another pharmacist or
the prescriber.
• Never guess the meaning of unrecognized abbreviation.
• Call the physician to verify the meaning of a prescription that is unclear.
• failure to specify the desired strength of a medication must be corrected.
• safety of the dose of the drug, dosage form must be taken into account.
LABELING
• The prescription label may be typewritten or
prepared by computer, using the information
entered by the pharmacist or pharmacy assistant.
• A prescription should have an aesthetic and
professional appearing label.
• The name and address of the pharmacy are legally
required to appear on the label; the telephone
number is also commonly included.
Prevention of Dispensing Errors
• Care must be exercised by the pharmacist in making certain that the
product dispensed is of the prescribed dosage, form, strength, and number
of dosage units.
• When substitution is permitted, the pharmacist is responsible for the
selection of the manufacturer’s product to use in filling the prescription.
• This responsibility on the basis of his knowledge of the quality,
effectiveness, and cost to the patient of the selected product.
• Products which look deteriorated or are past the stated expiration date on
the label should never be dispensed.
• The counting tray should be wiped clean after each counting, as powder,
especially from uncoated tablets, tends to remain on the tray.
• When a prescription requiring compounding is
received, the pharmacist should take into
consideration
– the chemical and physical compatibility of the
ingredients.
– the proper order of mixing.
– the need for special adjuvants or techniques.
– the mathematical calculations required.
RECHECKING
• Every prescription should be rechecked and the
ingredients and amounts used verified by the
pharmacist.
• Rechecking is especially important for those drug
products available in multiple strengths.
