DRUG

LOREM IPSUM
ERRORS
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What is a drug error?
A drug or 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. 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."
© 2019 National Coordinating
Council for Medication Error
Reporting and Prevention
Classification/Types

There are four broad types of medication

errors

1•Knowledge-based errors (through 2•Rule-based errors (using a bad rule

lack of knowledge) or misapplying a good rule)
—for example, giving penicillin, —for example, injecting diclofenac
without having established whether the into the lateral thigh rather than the
patient is allergic. In an Australian buttock. Proper rules and education
study, communication problems with help to avoid these types of error, as do
senior staff and difficulty in accessing computerized prescribing systems.
appropriate drug-dosing information
contributed to knowledge-based
prescription errors.1919 These types of
errors should be avoidable by being
well informed about the drug being
prescribed and the patient to whom it is
being given. Computerized prescribing
systems, bar-coded medication
systems, and cross-checking by others
(for example, pharmacists and nurses)
can help to intercept such errors.2020
Education is important 3
3•Action-based errors (called slips) 4•Memory-based errors (called
lapses)
—for example, picking up a bottle containing
diazepam from the pharmacy shelf when —for example, giving penicillin,
intending to take one containing diltiazem. In
the Australian study mentioned above most
knowing the patient to be allergic, but
errors were due to slips in attention that forgetting. These are hard to avoid;
occurred during routine prescribing, they can be intercepted by
dispensing or drug administration. These can computerized prescribing systems and
be minimized by creating conditions in which by cross-checking.
they are unlikely (for example, by avoiding
distractions, by cross-checking, by labelling
medicines clearly and by using identifiers,
such as bar-codes);2222 so-called ‘Tall Man’
lettering (mixing upper- and lower-case letters
in the same word) has been proposed as a way
to avoid misreading of labels,2323 but this
method has not been tested in real conditions.
A subset of action-based errors is the
technical error—for example, putting the
wrong amount of potassium chloride into an
infusion bottle. This type of error can be
prevented by the use of checklists, fail-safe
systems and computerized reminders.

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 CAUSES OF DRUG
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ERRORS
1.Prescribing Errors - Occurs when prescriber orders drug for specific patient drug
dose dosage form route of administration length of therapy number of doses
administration drug concentration inadequate or incorrect instructions for use
illegible handwriting

2. Omission Errors Failure to administer an ordered dose (not late dose)

Omitted dose is not an error when cannot take anything by mouth (NPO)providers
are waiting for drug level results patient refuses

3.Wrong Time Errors Standardized administration times acceptable interval

surrounding scheduled time Medications administered outside this window
considered wrong time errors Occasionally unavoidable patient is away care area for
test medication is not available at time it is due

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 CAUSES OF DRUG
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ERRORS
4.Unauthorized Drug Errors
Administration of medication to patient without proper authorization by
prescriberAdministration of medication outside established guidelinesMedication for
patient given to another patientNurse gives medication without prescriber
orderPatients “share” prescriptionsRefilling prescription that has no refills
remainingProtocols may allow flexibility-not unauthorized
5.Improper Dose Errors Dose that is greater or less than prescribed dose
Can occur when additional dose is administereddelay in documenting doseabsence of
documentationInaccurate measurement of oral liquidExclusions from this error
typetopical applicationsvariances that occur from apothecary to metric conversions
6.Wrong Dosage Form Errors
Doses administered as different form than orderedDepends on state laws & facility
guidelinesdosage form changes may be acceptableaccommodate particular patient
needsoften acceptable

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 CAUSES OF DRUG
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ERRORS
7. Wrong Drug Preparation Errors
Reconstituting oral suspension with incorrect volumeUsing
bacteriostatic saline instead of sterile water to reconstitute
lyophilized powder for injectionNot activating an ADD-
Vantage® IV admixture bag
8. Wrong Admin Technique Errors
Examples:subcutaneous injection that is given too
deepintravenous (IV) drug is allowed to infuse via gravity
instead of using an IV pumpinstilling eye drops in wrong eye
9. Deteriorated Drug Errors
Monitoring expiration dates is very importantDrugs used past
their expiration datemay have lost potencymay be less effective
or ineffectiveRefrigerated drugs stored at room temperature may
decompose & lose efficacy
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 CAUSES OF DRUG
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ERRORS
10. Monitoring Errors Inadequate drug therapy review
Examples:
ordering serum drug levels but not reviewing themnot
responding to level outside of therapeutic rangenot ordering
drug levels when requiredprescribing antihypertensive agent &
then failing to check blood pressure
11. Compliance Errors Failure to adhere to prescribed drug
regimen
Detected when refill requests not on timeExample:patient does
not complete antibiotics therapy-saves a few doses

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Management

• Identify the Right Patient

Identifying the right patient is the most important key in
preventing medication errors. You can do this by simply
asking the patient’s full name and date of birth to make sure
the information given matches your medication card.

• Ensure the right drug

When carrying out doctor’s orders, ensure that you are
dealing with the right drug. There are lots of drugs with
similar brand names like clonidine and klonopin,
celebrex and cerebryx and many more.
To ensure that you are dealing with the right drug, it will
be best to use both the generic and brand name of the Lorem ipsum dolor sit amet, consectetuer
medication ordered. Be careful as well with drug adipiscing elit. Maecenas porttitor congue
packaging as some medicines come in deceptively
similar packaging or canisters.
Management

• Check with your drug handbook

Whenever you are not sure with the drug you will administer,
don’t hesitate to double check with your drug handbook. A
drug handbook is a wealth of important information about
different drugs like adverse reactions, drug incompatibilities,
precautions and many more.
• Maintain clear communication
Sometimes, ordered medications are lost in
communication among doctors, nurses and
pharmacists. To avoid miscommunication, there
are simple things you can do in carrying out
doctor’s orders for new medications.
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adipiscing elit. Maecenas porttitor congue
Management
• Have a double-check buddy for high alert
drugs
High alert medication are so potent that a slight variation in
dosage given will directly affect the patient’s vital signs. For
this reason, it is important to have someone double check your
high alert medications before you administer them to your
patient.
High alert drugs include heparin, dopamine, dobutamine,
nicardipine, digoxin and many more.
• Ask patient about any drug allergies
before giving new medications
To avoid unnecessary adverse drug reactions, always ask
the patient about any known drug allergies before giving
new medications. There are some occasions where Lorem ipsum dolor sit amet, consectetuer
adipiscing elit. Maecenas porttitor congue
patients forget to state their drug allergies upon initial
history taking.
Management
• Learn as much as you can about
medications
Make reading a habit. Whenever you encounter an unfamiliar
drug, take the drug literature paper and study it.
You can also learn a lot from reading labels. If you have a
smart phone, try to install a drug index app as it will be handy
whenever you want to look up for a drug quickly.

• Clarify newly ordered medication if it

doesn’t seem right
There is nothing wrong in double checking
with your fellow health workers. If you
think a newly ordered medication will do
more harm to the patient than its intended Lorem ipsum dolor sit amet, consectetuer
therapeutic effect, clarify it with the doctor. adipiscing elit. Maecenas porttitor congue
Management
• . Create medication labels properly
It is not advisable to put drugs into another container but if
you must do it, label the new container properly. Indicate the
generic and brand name of the drug as well as dosage and
expiry date.
When creating this new medication label make sure that it is
readable. The font should be simple and narrow. It is also
more convenient if you will peel the old label from the
previous canister and stick it to the new canister
• . Be careful in crushing and cutting up
pills
Some tablets have extended release coatings. These
medications are usually antihypertensive and
hypoglycemic drugs. Be careful in crushing or cutting
them up as these drugs will produce quick potent effects Lorem ipsum dolor sit amet, consectetuer
when taken without the extended-release coating. adipiscing elit. Maecenas porttitor congue
If you must give the drug through a nasogastric tube,
clarify with the doctor first as you should not crush an
extended-release tablet.
Management
• Relate the patient’s case in carrying out
new medication orders
This is practical whenever you can’t read a poorly written
medication order or if you think there has been a
typographical error in the new order. Relating the patient’s
case in carrying out new medication orders is helpful in
making clarifications.
For example, a nurse is having trouble reading the newly
ordered medication for a 14 year old boy with seizures. The
written order reads like “prednisone” but considering the case
of the patient, the nurse decided to clarify with the doctor if
the patient really needs prednisone as part of his maintenance
drugs at home.
Upon clarification, the ordered medication is actually
Lorem ipsum dolor sit amet, consectetuer
“primidone”. Considering the patient’s case in carrying out adipiscing elit. Maecenas porttitor congue
new medication orders saved him from unnecessary adverse
drug reactions.
Management

• . Precautions in eardrops and eyedrops

To avoid medication errors, always keep the patient’s safety in
mind while giving their medications. If you are just new in
practicing the nursing profession, asking guidance from your
senior nurses is also helpful in preventing medication errors.
Seasoned nurses know more techniques in reducing the risks
of such mistakes so ask for their guidance and advice as you
start working in your unit.

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adipiscing elit. Maecenas porttitor congue
ARTICLES ON
DRUG ERRORS

16
ARTICLE IV
PENAL AND OTHER PROVISIONS
Section 28. Penalties. Any person found guilty of "illegal practice of medicine" shall be
punished by a fine of not less than one thousand pesos nor more than ten thousand pesos
with subsidiary imprisonment in case of insolvency, or by imprisonment of not less than one
year nor more than five years, or by both such fine and imprisonment, in the discretion of the
court.
Section 29. Injunctions. The Board of Medical Examiners may file an action to enjoin any
person illegally practicing medicine from the performance of any act constituting practice of
medicine if the case so warrants until the necessary certificate therefore is secured. Any such
person who, after having been so enjoined, continues in the illegal practice of medicine shall
be punished for contempt of court. The said injunction shall not relieve the person practicing
medicine without certificate of registration from criminal prosecution and punishment as
provided in the preceding section. Section 30. Appropriation. To carry out the provisions of
this Act, there is hereby appropriated, out of any funds in the National Treasury not otherwise
appropriated, the sum of twenty thousand pesos.
Section 31. Repealing clause. All Acts, executive orders, administrative orders, rules and
regulations, or parts thereof inconsistent with the provisions of this Act are repealed or
modified accordingly.
Section 32. Effectivity. This Act shall take effect upon its approval: Provided,
That if it is approved during the time when examinations for physicians are
held, it shall take effect immediately after the said examinations: Provided,
further, That section six of this Act shall take effect at the beginning of the
academic year nineteen hundred sixty to nineteen hundred sixty-one, and the
first paragraph of section seven shall take effect four years thereafter.
Section 24. Grounds for reprimand, suspension or revocation of registration
certificate. Any of the following shall be sufficient ground for reprimanding a
physician, or for suspending or revoking a certificate of registration as
physician:
(1) Conviction by a court of competent jurisdiction of any criminal offense
involving moral turpitude;
(2) Immoral or dishonorable conduct;
(3) Insanity;
(4) Fraud in the acquisition of the certificate of registration;
(5) Gross negligence, ignorance or incompetence in the practice of his or her
profession resulting in an injury to or death of the patient;
(6) Addiction to alcoholic beverages or to any habit forming drug rendering him or
her incompetent to practice his or her profession, or to any form of gambling;
(7) False or extravagant or unethical advertisements wherein other things than his
name, profession, limitation of practice, clinic hours, office and home address, are
mentioned.
(8) Performance of or aiding in any criminal abortion;
(9) Knowingly issuing any false medical certificate;
(10) Issuing any statement or spreading any news or rumor which is derogatory to
the character and reputation of another physician without justifiable motive;
(11) Aiding or acting as a dummy of an unqualified or unregistered person to
practice medicine;
(12) Violation of any provision of the Code of Ethics as approved by the Philippine
Medical Association.
https://www.slideshare.net/maryline1979/medication-error-25474916?
next_slideshow=1
Examples from the Philippines: Actual cases
Introduction: The Philippine Generic Drug Law of 1988 mandates that the labeling,
prescription of drugs be done in generic or scientific nomenclature, with intention
towards promotion of more affordable drugs and rational drug use.
The use of generic terms in prescription lessen chances of medication errors. Pharmacists
validating prescriptions and checking important patient and drug details help prevent
errors. Some case examples are presented here.
Mesulid vs Mellaril. The doctor prescribed Mesulid, without indicating nimesulide (the
generic name), the pharmacist gave Mellaril (thioridazine) instead. Patient had to be
hospitalized.

Ceporex vs Leponex. A doctor prescribed Ceporex, a trade name of an antimicrobial but

the drugstore gave Leponex instead, a psychotropic medicine. Again, the patient had to be
hospitalized.
Thiamine vs Thorazine. Even when using generic drug names, errors can still occur.

Thiamine was prescribed to a 2-year-old boy; instead, thorazine was given by the
drugstore clerk. The dispensing individual did not see the importance of checking why
thorazine should be given to a 2-year-old boy.
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Terbulin vs Theodur. A young asthmatic patient was given Theodur (a trade name
product containing theophylline) by a doctor. On top of this, the doctor gave Terbulin, (a
fixed dosed combination product trade name) mistakenly thinking that this is terbutaline
alone but in fact contained theophylline as well. Patient went into theophylline toxicity,
was hospitalized.
EMB vs EMBR Tuberculosis patient was prescribed quadruple anti-Koch medications.
The doctor abbreviated ethambutol as EMB but the patient was given instead the brand
EMB a combination INH and ethambutol. Liver transaminases became elevated as the
isoniazid dosage was more than necessary.
Unclear expiry dates. A patient had died due to a serious illness. Being attributed was
the hospital staff using alleged expired medicine. The hospital misinterpreted the marked
expiry date as month-day-year where in fact, should have been read as day-month-year.
The national drug regulatory agency failed to note and standardize labeling as
manufacturing and expiry dates presentation may vary from country to country.
Mislabelling of IV fluids. A patient kept on NPO became hypoglycemic because the
intravenous fluid (0.9 saline) was mistakenly labeled by the nurse as D5-0.9 saline for a
number of shifts until the doctor found the source of the problem by opening the IVF
cover.

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Terbulin vs Theodur. A young asthmatic patient was given Theodur (a trade name
product containing theophylline) by a doctor. On top of this, the doctor gave Terbulin, (a
fixed dosed combination product trade name) mistakenly thinking that this is terbutaline
alone but in fact contained theophylline as well. Patient went into theophylline toxicity,
was hospitalized.
EMB vs EMBR Tuberculosis patient was prescribed quadruple anti-Koch medications.
The doctor abbreviated ethambutol as EMB but the patient was given instead the brand
EMB a combination INH and ethambutol. Liver transaminases became elevated as the
isoniazid dosage was more than necessary.
Unclear expiry dates. A patient had died due to a serious illness. Being attributed was
the hospital staff using alleged expired medicine. The hospital misinterpreted the marked
expiry date as month-day-year where in fact, should have been read as day-month-year.
The national drug regulatory agency failed to note and standardize labeling as
manufacturing and expiry dates presentation may vary from country to country.
Mislabelling of IV fluids. A patient kept on NPO became hypoglycemic because the
intravenous fluid (0.9 saline) was mistakenly labeled by the nurse as D5-0.9 saline for a
number of shifts until the doctor found the source of the problem by opening the IVF
cover.

22
A story of medication error in the hospital.
An oncologist wrote instructions on the hospital chart for the IV administration of the
oncolytic drug mesna (brand name Uromitexan), but the nurse mistook it for the
respiratory solution also called mesna (brand name Mistabron). The respiratory solution
meant for nebulization was injected intravenously for a total of 8 doses over a period of 3
days until the error was discovered.
Patient was never told of the error by the attending physician and was, in fact, sent home
on the same night. Some tests were ordered but these were never carried out. Drug
industry help was sought on pharmaceutical physico-chemical information but they could
not be contacted over the weekend.
The Philippine FDA was informed of the incident on Monday and they were surprised
how they managed to register two drugs sharing the same name.
The doctor, in following the Philippine Generics Act of 1988 mandating that the doctor
should write the generic name of a prescribed drug, was unclear about his responsibility
to indicate the specific product trade name.
The nurses (three shifts over three days) did not read the ampoule information prior to
administration. The hospital pharmacist sent the ampoules to the floor without an
accompanying box or product information leaflet.
https://www.pcp.org.ph/index.php/component/content/article?id=211:chapter-4-
Patient could not be followed up.
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