Medication error

Medication errors are a major concern in the healthcare fraternity. Although unintended, medication errors continue to happen everyday resulting in patient harm.

1. PUNE ADVENTIST HOSPITAL Training on:

2. Medication error A preventable event that may cause or lead to inappropriate  medication  use or patient harm while the  medication  is in the control of the healthcare professional, patient, or consumer

3. Near miss An event or situation that happens by chance but doesn’t produce patient injury. A near miss is considered an error.

4. Factors contributing to medication errors Human related System related Medication related

5. Human related factors HCP Over worked Under trained Competence Distracted Illness Stress Patients In a hurry Health literacy level Do not understand medication use Trust providers to not make mistakes

6. System – related factors Lack of communication Poor workflow Disorganized workspace Inadequate tools to complete work Lack of supervision

7. Medication – related factors Look alike/ sound alike medications Multiple dosage forms and strengths

8. 6 Rights Right drug Right route Right time Right dose Right patient Right dosage form

9. Types of medication errors Prescribing error Dispensing error Documentation error Administration error Transcription error Indent error

10. Prescribing error Occurs as a result of a faulty prescribing decision or prescription writing process. It includes: incorrect prescription Illegible handwriting Drug allergy not identified Irrational combinations Out of list abbreviations

11. When prescribing... Always use S ign. N ame, D ate T ime (SNDT) format, all capitals Always use decimal points for dosage, and 0 before the decimal point rather than after the digit

12. Dispensing error Currently, the accuracy stands at 98.3% in dispensing medication 1.7% inaccuracy and error

13. Prevalent dispensing errors Dispensing incorrect medication, dosage strength or dosage form Dosage miscalculation Failure to identify drug interactions or contraindications

14. LASA medication

15. Errors of omission Failure to counsel the patient Failure to screen for drug interactions and contraindications

16. Errors of commission Miscalculation of a dose Dispensing the incorrect medication dosage strength or dosage form

17. Dispending errors: common causes Work environment Workload Distraction Work area Use of outdated or incorrect references LASA drugs

18. Prescribing, Dispensing error e.g.

19. Administration error A discrepancy between drug therapy received by the patient and therapy intended by the prescriber. Accounts for 26% - 32% of total medication errors Involves discrepancy in one of the 6 - Rights

20. Causes of Administration Errors Failure to check patient’s identity Wrong calculation to determine correct dose Poor lighting Noise interruption Lack of knowledge of the preparation or administration Complex design of equipment

21. Administration error e.g. The nurse is catching up on all patients morning medication Patient’s condition deteriorates and he is intubated The nurse decides to crush all medicines and administer via NG tube Crushes an extended – release Ca channel blocker Patient’s heart rate slows to asystole , patient dies

22. Transcription error Factors contributing to transcription error are Illegible prescription Use of abbreviations Lack of familiarity with drug names

23. Indent Error