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Medication errors
This document discusses medication errors, including their definition, causes, types, and strategies to prevent them. Some key points: - Medication errors are preventable events that may cause harm and can occur at any stage from prescribing to administration. They are common but underreported. - Errors are often due to look-alike or sound-alike drug names, miscommunication, lack of knowledge, and environmental factors like interruptions. - Common types of errors include prescribing errors, dispensing errors, and administration errors. Analgesics, antibiotics, anticoagulants are high-risk drug classes. - Prevention strategies include education, standardized processes, double checks, limiting distractions, clear
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Medication errors
- 1. Medicatio n Errors Guided by Dr.V. M. Motghare Prof & Head Dept. of Pharmacology Dr. Swarnank Parmar JR-2 Dept. of Pharmacology GMC, Nagpur 1
- 2. Overview • Definition • Epidemiology •Classification • Causes of errors • Factors contributing & risks • Steps to prevent medication errors • Summary 2
- 3. Definition • “Any preventableevent that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient, or consumer” • May occur at any time, from the prescription to consumption of the medicines by the patient • Problems & sources of medication errors are multidisciplinary & multifactorial 3
- 4. • Errors occurfrom- – Lack of knowledge – Unclear or erroneous labeling of drug – Misidentification of patient – Mental lapses or – Verification errors • Errors committed by both experienced & inexperienced staff 4
- 5. Epidemiology • Interesting buthorrifying fact- - More people in USA die in a given year as a result of medical errors than from motor vehicle accidents, breast cancers, or AIDS • Majority are medication errors • Indian study of paediatric intensive care unit reported 68.5% of all errors were medication errors 5
- 6. • Reported epidemiologyof this iatrogenic disease related to medication error- tip of the iceberg • Numbers reported can be misleading due to- Small % of errors & adverse drug events detected, even smaller number are reported Inconsistencies in way the errors reported & counted Most studies have looked errors only in inpatient settings Most studies focus on errors of commission(fails to consider errors of omission) 6
- 7. Classification Errors When actions areintended but not performed Mistakes Errors in planning action Skill based errors (slips & lapses) Errors in executing correctly planned actions Knowledge- Based errors 2. Rule- based errors 2a. Good rules not applied or misapplied 2b. Bad rules 3. Action-based errors (slips) 4. Memory-based errors(lapses) 3a. Technical errors 7
- 8. Intention Mistakes Plan cannot reach target Intended outcome Slip/Lapse Errorin implementing plan Check 8
- 9.
- 10. • Errors ofOmission: errors related to prescription, drug dispensing by pharmacist, drug administration by medical personnel like nurses & patient themselves • Errors of Commission: most common form of errors encountered in clinical practice, this include – 1.) Wrong phenomenon 2.) Drug interaction related 3.) Communication failure 4.) Failure to follow appropriate policies related to drug use 5.) Failure to follow drug-specific instructions 6.) Overuse of a drug(irrational drug use & polypharmacy) Causes of errors 10
- 11. 1. “Wrong” phenomenon– - Wrong drug, wrong dose, wrong substitution for a drug, wrong patient, wrong regimen, wrong route 2. Drug interaction related errors – - Food-drug interaction, drug- drug interaction or interactions with other alternative forms of medicine - Responsible for medication errors, which may lead to serious adverse events, sometimes hospitalization or death of patient 11
- 12. 3. Communication failure– - Failures during the process of patient management - Includes illegible handwriting, incomplete prescribing order, vague instructions, prescription not recognized & unknown prescriber - Common errors include: ‘g’ mistaken for ‘mg’, ‘4’ mistaken for ‘U’, decimal point(‘.1’ read as ‘1’) 12
- 13. • Some otherrecognized types of medication errors- Incomplete patient information Drug information unavailable Miscommunication of drug orders Confusion in drug names Misuse of zeros & decimal points Confusion in dosing units Inappropriate abbreviations 13
- 14. Swiss Cheese Model •Pictorial model for medication errors • Defences against error displayed as thin layers with holes that describes latent errors in system • Each layer successively represents the prescriber, pharmacist, nurse & patient related defences • Missed error successively at various defence levels, reaches the patient 14
- 15.
- 16. Types of errors •Prescribing errors • Dispensing errors • Administration errors 16
- 17. Prescribing errors Incorrect drug selectionfor a patient Errors in quantity & indication Prescribing contraindicated drug 17
- 18. Factors contributing Lackof knowledge of the prescribed drug, dose, patient details Illegible handwriting Inaccurate medication history taking Confusion with the drug name Inappropriate use of decimal points Use of abbreviations (e.g. AZT) Use of verbal orders 18
- 19.
- 20. Risk factors forprescribing errors Work environment & workload Miscommunication within team Physical & mental well being Lack of knowledge Inadequate training Low perceived importance of prescribing Absence of self awareness of errors 20
- 21. Reducing prescribing errors •Electronic prescribing reduces errors due to illegible handwriting 21
- 22. • Computerized physicianorder entry system eliminates need for transcription orders by nursing staff 22
- 23. Dispensing errors • Receiptof the prescription supply of a dispensed medicine to patient • Occurs primarily with drugs having similar name or appearance • Example :lasix® (frusemide) and losec® (omeprazole) • Other potential dispensing errors include – wrong dose – wrong drug or – wrong patient 23
- 24. Reducing dispensing errors •Ensuring a safe dispensing procedure • Separating drugs with similar name or appearance • Unit dose medication dispensing • Automated medication dispensing system • Bar code medications for dispensing & administration (patient given barcoded wristband) 24
- 25. Administration errors • Discrepancybetween drug received by patient & drug therapy intended by prescriber • Errors of omission - the drug is not administered • Incorrect administration technique & administration of incorrect or expired preparations • Deliberate violation of guidelines 25
- 26. Contributing factors • Failureto check patient’s identity prior to administration • Environmental factors such a noise, interruptions, poor lighting • Wrong calculation to determine the correct dose 26
- 27. Reducing administration errors •Checking patient’s identity. • Ensuring dosage calculations are cross checked independently by another health care professional before drug is administered • Ensuring medication given at correct time • Minimizing interruptions during drug rounds 27
- 28. Drugs commonly associatedwith medication errors • Analgesics- – Unnecessary use of opioid analgesics (over sedation of patient) – Errors reported are due to wrong route of administration – Failure to monitor clinical parameters (heart rate, respiration & blood pressure), resulted in major adverse outcomes related to opioid use 28
- 29. • Antibiotics- Irrationaluse • Anticoagulants- Inadequate therapeutic dosing Failure to monitor blood levels • Cardiovascular agents- Errors due to overdose Failure to identify drug-drug interactions due to polypharmacy 29
- 30. • Diabetic medications- –Overdose of hypoglycemic drugs (insulin) – Overenthusiastic patients trying to keep blood glucose within normal limits – Failure to take drugs in relation to meals – This group of drugs signifies importance of patient education by treating physicians 30
- 31. LOOK ALIKE SOUNDALIKE • Existence of confusing drug names is one of the most common causes of medication error • With thousands of drugs currently in market, potential for error due to confusing drug names is significant • Contributing factors are – illegible handwriting, – incomplete knowledge of drug names – newly available products, – similar packaging or labelling – similar clinical use – Similar strengths, dosage forms, frequency of administration 31
- 32. Major effect ontherapeutic success Brand name(Generic name) Brand name(Generic name) Benzol (Danazol) Benzole (Albendazole) Alparazole (Alprazolam) Adprazole (Omeprazole) Amsat (Ampicillin) Amset (Amlodipine) Adcom (Telmisartan) Adcon (Fluconazole) Alflox (Norfloxacin) Alfox (Oxcarbazepine) Dazolic (Ornidazole) Dazolin (Sertraline) 32
- 33. Minor effect ontherapeutic success Brand name(Generic name) Brand name(Generic name) Aquamide (Furosemide) Aquazide (Hydrochlorthiazide) Disprin (Aspirin 350mg) Dospin (Aspirin 75mg) Epitab (Phenytoin) Epitan (Phenobarbitone) Ostofit (Glucosamine) Ostrobit (Ca. carbonate) Wormnil (Mebendazole) Wormonil (Albendazole) 33
- 34. No significant effecton therapeutic success Brand name(Generic name) Brand name(Generic name) Avcif (Cefixime) Avcip (Ciprofloxacin) Atmox (Amoxicillin) Atrox (Roxithromycin) Cefit (Cefixime) Cefiz (Cefpodoxime) Ceftab (Cefuroxime) Ceftas (Cefixime) Deplin (Sertraline) Depnil (Clomipramine) 34
- 35.
- 36. Strategies to preventerrors by LASA drugs • Use of novel dosage delivery devices to distinguish products with similar names • Print generic and brand names on unit-dose packaging, when possible • Use of TALL MAN lettering to emphasize the spelling of drug names in medication storage areas (e.g. lamIVUDine & lamOTRIGine ) • Include dosing limits for medications with similar indications 36
- 37. Steps to preventmedication errors Targeted physician education on optimal medication use Inclusion of clinical pharmacists in decision making activities Computerized order entry by prescriber & medication checking Standardize processes & equipment Avoid use of unknown abbreviations & symbols Double check patients having allergies before prescribing 37
- 38. Check the expirydate of the drug before administration Medication Reconciliation Standardised ordering and administration Training, education, and organisational interventions Preparing medicine in well lighted room 38
- 39. Six step approachby WHO for good prescribing • Evaluate & clearly define patient’s problem • Specify therapeutic objectives • Select appropriate drug therapy: P-drug & STEPS approach (Safety, Tolerability, Effectiveness, Price, Simplicity) • Initiate therapy with appropriate details • Give information, instructions & warnings • Evaluate therapy regularly (e.g. Monitor treatment results)39
- 40. Role of regulatoryauthorities • Important role in preventing medication errors • Review of drug labels & nomenclature greatly enhances preventive strategies • FDA provides guidance to industry to maintain proper drug labels • Public education by regulatory agencies improves medication use • Emphasis laid on having package insert in vernacular languages 40
- 41. Role of organizations •Computer software installation by FDA to analyze similar drug names • Potentially confusing names rejected • FDA reviews 300 brand names in a year before they are marketed to avoid confusion of LASA drugs • FDA encourages pharmacists & other health professional to report any medication errors 41
- 42. Role of prescribers •Doctors should have knowledge of generic names & brand names of available drugs in their local setting • Specify dosage form, drug strength & complete directions on prescriptions • Using both brand name & generic name on prescription • Purpose of medication • Legible handrwiting 42
- 43. Role of Pharmacist •Refer back to doctor if any confusion • Basic knowledge of dosing regimens for commonly used drugs • Computer reminder for serious confusing name pairs to avoid errors in prescription • Stickers of ‘Alert’ in areas where LASA drugs stored • In case of wrong prescription, pharmacist should not react in front of patient 43
- 44. Role of nursingstaff • Education & proper training important in reducing medication related errors • Most errors do not reach patient because of barrier role played by a nurse • Independent calculations of paediatric doses by more than one person • Should be aware of correct storage requirements for drugs • Development of standardized dose & rate charts for products such as vasoactive drugs 44
- 45. Patient & Physicianeducation • Regular short courses/training to junior residents by academic institution for good prescription writing practices • Prescriber should also consider – – Age of patient – Any physical disability – Weak eye sight, before prescribing • Patient educated regarding correct use of prescription & over the counter medicines 45
- 46. • Patient shouldconfirm name & strength of prescribed drugs before leaving doctor’s office • Educated about the storage conditions of drugs (e.g. Insulin) • Keeping medicines away from reach of children also should be emphasized • Patient should carry all previous prescriptions to avoid repeating the drug or notice any change in prescriptions 46
- 47. Summary •Stay alert ! •Question! •Learn ! 47
- 48. Referneces • Medication Errors:Causes & its prevention, Singh I, Shafiq N, Malhotra S;Drugs Bulletin Vol.XXXVI No. 2, April 2011 • British journal of clinical pharmacology;67:6, 2009 • Look alike & Sound alike drug brand names; Mukundraj S Keny, PV Rataboli; Indian journal of clinical practice, Vol. 23, no.9, February 2013 48
- 49.
Editor's Notes
- #5 including physicians, pharmacists, nurses, students, clerical staff, administrators, pharmaceutical manufacturers, patients & their caregivers
- #19 Zero should always precede a decimal point (e.g. 0·1). Use of a trailing zero (e.g. 1·0).
- #25 Barcoded wristband which is scanned & transmitted to the persons involved in drug dispensing & administration
- #40 P-drugs – effective, inexpensive, well- tolerated drugs that physicians regulary prescribe to treat common problems As a doctor you may see 40 patients per day or more, many of whom need treatment with a drug. How do you manage to choose the right drug for each patient in a relatively short time? By using P-drugs! P-drugs are the drugs you have chosen to prescribe regularly, and with which you have become familiar. They are your priority choice for given indications. The P-drug concept is more than just the name of a pharmacological substance, it also includes the dosage form, dosage schedule and duration of treatment. P-drugs will differ from country to country, and between doctors, because of varying availability and cost of drugs, different national formularies and essential drugs lists, medical culture, and individual interpretation of information. However, the principle is universally valid. P-drugs enable you to avoid repeated searches for a good drug in daily practice. And, as you use your P-drugs regularly, you will get to know their effects and side effects thoroughly, with obvious benefits to the patient.
- #41 Many errors related to drug names & improper instructions on drug label-