Medication error- Etiology and strategic methods to reduce the incidence of Medication Errors

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

1. MEDICATION ERROR Dr. Jibin Mathew Clinical Pharmacologist

2. Medication Errors "A medication error is any preventable event that may cause or lead to inappropriate medication use or patient Any preventable event that may cause or lead to in inappropriate medication use or patient harm due to : Wrong patient Wrong medication Wrong dose Wrong route Wrong time Wrong documentation

3. Medication Process Indenting

4. Types of Medication Errors Prescription error Transcription error Indenting error Dispensing error Administration error Monitoring error

5. Error Factors often Arises in medication administration Poor communication Carelessness Multiple interruptions Stress Lack of knowledge working conditions

6. Causes of Errors Factors associated with health care professionals Physical problems , Tired , unwell, stressed etc . Lack of protocols or policies Lack of training Verbal rather than written culture Time pressure & Staff turnover Poor communication with healthcare staffs Lack of support from other healthcare professionals

7. Causes of Errors Factors associated with patients Lack of patient awareness of medicines Patient characteristics (e.g., personality, literacy and language barriers) Complexity of clinical case, including multiple health conditions , polypharmacy and high-risk medications

8. Causes of Errors Factors associated with the work environment Workload and time pressures Distractions and interruptions (by both primary care staff and patients) Lack of standardized protocols and procedures Insufficient resources Issues with the physical work environment (e.g., lighting, temperature and ventilation)

9. Causes of Errors Factors associated with medicines Naming of medicines Labelling and packaging Storage of medicine

10. High Risk Areas for Medication Errors High alert medications High risk patients ( (Pregnant, Elderly, HIV, Transplant Patients, Anticoagulants, Pediatric Patients, Psych Patients) High risk diseases Infusion pumps ( High Risk Medications, Incorrect Pump Programming, Calculation / Concentration Errors, Wrong Medication) Verbal orders Abbreviations Look-alike drugs

11. Prominent reasons enhancing Medication Error Look Alike & Sound Alike drugs Non compliance in Drug Standard Timing Units while prescribing drugs Prohibited Abbreviations Illegibility in prescription Unavailable Drug Information Independent Cross Checking High Risk Medications Medication Reconciliation and its documentation

12. Medication Errors : High Alert Medications Chemotherapeutic drugs Potassium Chloride Opiates and narcotics Insulin and oral hypoglycemic agents Anticoagulants (Heparin) Antihypertensive agents Psychiatric medication Anticonvulsants Cardiac drugs

13. Analysis of Administration Error

14. Case Study

15. Accidental administration of epinephrine instead of midazolam A 50-year-old women who was accidentally administered epinephrine instead of midazolam during colonoscopy preparation. The patient originally presented to the hospital with a history of abdominal pain and altered bowel habits. A colonoscopy was scheduled following administration of what was believed to be midazolam 5 mg. She then started to complain of chest tightness, difficulty breathing, and generalized tremors. It was soon discovered that a medication error occurred and the patient was instead administration 0.25 mg of epinephrine instead of midazolam. The procedure was postponed for several days until the patient recovered.

16. A root cause of the error revealed that the epinephrine ampule was mistakenly placed in the box with the midazolam in the pharmacy following an instance where a previous patient did not require the medication. Ampules of both medications were similar in size, shape, and color . As a result, the hospital initiated new procedures to ensure regular reviews of drug containers and their contents and double checking medication names before administration .

17. Unintentional administration of insulin instead of influenza vaccine 5 adult patients unintentionally received insulin instead of the influenza vaccine. The mix-up occurred at a public school clinic in Missouri and was discovered following an investigation from the government. Officials learned that a school nurse inadvertently administered Humalog U-100 insulin instead of the influenza vaccine. Acute hypoglycemia was reported in all 5 patients who received the insulin with varying degrees of symptoms.

18. After the first 2 patients complained of sweating and lightheadedness, the nurse reported the incidents to the supervising nurse, but did not stop administering vaccines. Two later patients would require hospitalization for their symptoms, one of which was documented to have a blood glucose level of 23 mg/ dL . The investigation revealed that the influenza vaccine vial was kept in the nurse’s office refrigerator along with a 10 mL vial of Humaog U-100 insulin ; they were found to not be stored in separate, labeled containers or bins.

19. MEDICATION ERROR ANALYSIS MONITORING TRAINING Medication Error MANPOWER DOCUMENTATION S hortage of doctors I nfrequent audits N o over sight by Nursing TL Lack of knowledge & Staffs untrained on Medication administration Doctors are not trained on medication reconciliation Staffs not sensitised about medication error Documented before administration New Nursing staff Joined Wrong transcription No Documentation Wrong documentation N o over sight of Doctors notes Cross checking was not happen COMMUNICATION Hand Over communication was not proper Communication Gap between doctors and Nursing ; Nursing , Pharmacist and Doctors PRESCRIPTION Escalation not happen I ncomplete Prescription Illegible handwriting Special instruction was not written S hortage of Pharmacist Pharmacist are not trained

20. Ways to Prevent Medication Errors Follow and practice “ Rights of Drug” administration, the ways to prevent these errors are: Don’t administer any drug without a doctor’s order. Always check the label to identify a drug. Don’t rely on the drugs color, shape, or location in the medication case. Check the label against the doctors order and the patient’s medication administration record (MAR ) two times : when obtaining the drug, when preparing the dose.

21. If you have any doubts about the drug you are giving, call the doctor Check expiration dates, and return out dated drugs to the pharmacy. Ask senior nurse to double check your dosage calculations. Don’t give drugs another nurse has prepared. The nurse should have verified the dosage before giving the drug-and she should to followed a basic administration rule, “If you don’t know a drug and it’s dosage, don’t give it until you find out Don’t try to interpret illegible handwriting even in ask the physician. Identify the patient by his ID band- don’t just ask his name or check his bed number. Use appropriate documentation on the MAR (Medication Administration record) helped to prevent errors.

22. Educating health care providers and patients Educating primary care providers about common causes of medication errors Providing simple tools to assist primary care providers in safe medication prescribing and use process Considering how patients can be actively involved in medicine management Providing patient engagement tools to address non-adherence Implementing medication reviews and reconciliation Ensuring that pharmacists actively review prescriptions Encouraging and supporting use of medication reconciliation by clinicians Using computerized systems Computerized provider order entry with decision support may be particularly effective when targeted at a limited number of potentially inappropriate medications and when designed to reduce the alert burden by focusing on clinically-relevant warnings.

23. THANK YOU !!!!