MEDICATION ERRORS

Professor A.O. Isah

Consultant Physician/Clinical
Pharmacologist
UNIBEN/UBTH
Benin City
 MEDICATION ERROR
 Medication error is any preventable event
where a dose of medication that is received
by a patient differs from what the prescriber
has prescribed, or from hospital policy and
procedures. (AHSP 1999)

 2% of hospital in-patients
 A Medication Error is a failure in the
treatment process that leads to or has the
potential to lead to harm to the patient
Ferner and Aronson 2006
 Medication Errors
The failures refer to the following:
 Manufacturing or compounding
 Prescribing
– Prescribing faults - failures in the process of deciding which drug to use
and how
– Prescribing errors – failures in the prescription writing process that
result in wrong instructions about one or more of the normal features of
a prescription
 Transcribing
 Dispensing
 Administration of a medicinal product
 Monitoring of its effects Aronson JK
2009
MEDICATION ERRORS - implications

 Therapeutic failure
– Increased Morbidity
– Prolonged hospital stay(4.6 days – Bates et al
1997)
– Mortality (7000 deaths /yr in USA –Phillips
and Christenfeld 1998)
MEDICATION ERRORS - implications

 Economic consequences
– Wasted resources
– Increased cost of care ( US $ 4700 /admission,
prolonged hospital stay 4.6 days – Bates et al 1997)
– Loss of man hours/ absenteeism form school
– Personnel

 Adverse Drug Reactions

 MEDICATION ERRORS
occuring in the process of prescribing, dispensing
and administration
 Prescribed medication not given
 Administration of a drug that was not
prescribed
 Medicine given to the wrong patient
 Wrong medicine or IV fluid administered
 Wrong dose or strength given
 MEDICATION ERRORS
occuring in the process of prescribing, dispensing
and administration
 Wrong dosage form given, for example eye
drops instead of ointment
 Wrong route of administration
 Wrong rate of administration, e.g IV infusion
 Wrong time or frequency of administration
 Medicine given for the wrong duration
 MEDICATION ERRORS
occuring in the process of prescribing, dispensing
and administration

 Wrong preparation of a dose e.g incorrect dilution of a

dose, not shaking a suspension

 Incorrect administration technique e.g unsterile injection

technique or incorrect installation of eye ointment

 Medicine given to a patient with known allergy

 MEDICATION ERRORS
factors contributing to..
 High staff workload and fatigue
 Inexperienced and inadequately trained staff
 Inattention, distracted, rushed,
 Poor communication among health-care workers
– Poor handwriting
– Ambiguous verbal orders
 Environmental factors
– Poor lighting
– Much noise
– Frequent interruptions
 Increased number or quantity of drugs per patient
 MEDICATION ERRORS
factors contributing to..
 Frequency and complexity of calculations needed to
prescribe, dispense and administer the drug
 Large number of formulary medicines and dosage
forms (such as injections) that are associated with more
errors
 Confusing drug nomenclature, packaging or labelling
 Lacking of effective drug policies and procedures
 The Dispensing Process
 Receive Prescription
 Interpret Prescription
 Retrieve Medication/Ingredients
 Prepare and Process
 Communicate with Patient
 Assure Patient's Understanding
 Monitor Adherence by Patient
 Keep Records
 Potential Error/Problems
 Wrong interpretation of prescription (or diagnosis)
 Retrieval of the wrong drug from stock
 Wrong dosages
 Inadequate packaging/labeling
 Inaccurate counting, compounding
 Inadequate or nonexistent labeling
 No knowledge of proper drug adherence
 Insufficient knowledge of the disease process
 Insufficient time to talk with patients about their drugs
 Inability to communicate to patients about therapy
Assessing Dispensing Conditions
 Dispensing point conditions
 Dispensing time? Communication time?
 How often do errors occur?
 Who is responsible for dispensing?
 Dispensing training in country?
 Salaries and wages for dispensers?
 Dispensing packaging?
 Practical Methods to detect ME and
associated drug-related events
 Chart review
 Computerized monitoring
 Administrative databases
 Claims data
 Direct observation
 Incident monitoring
 Voluntary reporting
 Patient monitoring
 MEDICATION ERRORS – methods of
prevention
 Establishing a consensus group of physicians,
pharmacists and nurses to select best practices

 Introducing a punishment-free system to collect and

record information about medication errors

 Developing written procedures with guidelines and

checklists for the administration of iv fluids and high
– risk drugs such as insulin, heparin and narcotics
 MEDICATION ERRORS – methods of
prevention
 Developing standardized times to administer
medicines and a policy to do so only when patients are
on the wards
 Requiring that a patient’s identity be confirmed before
administering a drug
 Allowing verbal or telephone orders only in an
emergency
 Requiring legible handwriting and complete spelling
of a drug name
 Requiring the use of standardized notation
 MEDICATION ERRORS – methods of
prevention
 Dose units written in one way only e.g. microgram not
g; g not gm
 Use of leading zeros for values less than 1 e.g 0.2 instead
of .2 and avoidance of trailing zeros for values more than
1 e.g. 2 instead of 2.0
 Requiring that the route of administration and the
complete directions (e.g ‘daily’ not ‘OD’) be written on
all drug orders (prescriptions)
 Requiring that prescribers write generic and brand names
for medicines with ‘look-alike’ or ‘sound-alike’ names.
 MEDICATION ERRORS
Prevention
 Education in the art of practical prescribing

 Ability to take medication history accurately

 Examine the patient for evidence of drug effects

 Investigate drug action at the bedside

 Plan appropriate therapy for common indications

 Calculate appropriate dosage regimens

 MEDICATION ERRORS
Prevention
 Write safe and legal prescriptions

 Appraise critically the prescribing of others

 Provide patient with appropriate information about

their medicines

 Access reliable information about medicines

 Detect and report ADR/AE/DI

 MEDICATION ERRORS
Prevention
 Educate Pharmacist

 Compulsory assessment (undergraduate prescribing

examinations)

 At postgraduate levels CPD/CME

 Use of standardized prescription charts

 Medication Errors
Recommendations (EMERGE 2008)
 Provision of sufficient undergraduate learning
opportunities to make medical students safe prescribers

 Provision of opportunities for students to practise skills

that help reduce errors

 Education of Students about common types of

medication errors and how to avoid them

 Education of prescribers in taking accurate drug histories

 Medication Errors
Recommendations (EMERGE 2008)
 Assessment in medical schools of prescribing
knowledge and skills and demonstration that newly
qualified doctors are safe prescribers

 European harmonization of prescribing and safety

recommendations and regulatory measures, with
regular feedback about rational drug use

 Comprehensive assessment of elderly patients with

declining function
 Medication Errors
Recommendations (EMERGE 2008)
 Exploration of low dose regimens for elderly patients and
preparation of special formulations as required

 Training for all health-care professionals in drug use,

adverse effects and medication errors in elderly people

 More involvement of Pharmacists in Clinical practice

 Introduction of integrated prescription forms and national

implementation in individual countries
 Medication Errors
Recommendations (EMERGE 2008)

 Development of better monitoring systems for

detecting medication errors , based on classification
and analysis of spontaneous reports of previous
reactions and for investigating the possible role of
medication errors when patients die

 Use of IT systems when available to provide

methods of avoiding medication errors;
standardization, proper evaluation and certification
of clinical information systems
 Medication Errors
Recommendations (EMERGE 2008)

 Nonjudgmental communication with patients

about their concerns and elicitation of symptoms
that they perceive to be adverse drug reactions

 Avoidance of defensive reactions if patients

mention symptoms resulting from medication
errors
THANKS FOR LISTENING