Medication errors

Errors

1. Medication Errors
SreenuThalla
Clinical Pharmacologist

3. WHY FOCUS ON MEDICATIONS?
•Thesuccessoftreatingillnessandtopreventdiseasehave
resultedindramaticincreaseinmedicationusewhichlead
tomedicationerrors.
•Differentroutesofadministration
•Multipledrugsusage
•Multipleprescribers
•Multiplepharmacologicaleffectsofadrug

4. What student needs to know?
Knowledgerequirements
•Tounderstandscaleofmedicationerrorandassociatedrisksof
medicationusage
•Commonsourcesoferror
•Tounderstandwhereintheprocesserrorscanoccur
•Understandadoctorsresponsibilitieswhileprescribingand
administeringmedication
•Torecognizecommonhazardoussituations
•Tolearnsafemedicationusage
•Tounderstandbenefitsofmultidisciplinaryapproachtomedication
safety.

6. •MedicationErrorsaredefinedasanypreventable
eventthatmaycauseorleadtoinappropriate
medicationuseorpatientharmwhilethemedicationis
inthecontrolofthehealthcareprofessional,patient,or
consumer.

7. STEPS IN USING MEDICATION
PRESCRIBING ADMINISTRATION
MONITORING

8. Where Do They Occur?
Prescribing
Transcription
Administering
Dispensing
Packaging
Monitoring

11. Types of Medication Errors
Prescribingerrors
Omissionerrors
Wrongtimeerrors
Unauthoriseddrugerrors
Improperdoseerrors
Wrongdosagefromerrors
Wrongdrugpreparationerrors
Wrongadministrationortechniqueerrors
Deteriorateddrugerrors
Monitoringerrors
Complianceerrors
Othererrors

13. MONITORING ERRORS
•Inadequatemonitoringforside-effects.
•Medicationnotceasedoncecourseiscomplete.
•Courseofprescribedmedicationnotcompleted.
•Druglevelsnotmeasured,ormeasuredbutnot
checked.
•Communicationfailures.

15. LIST OF LOOK ALIKE DRUGS
LETTERS CONFUSED WITH
acetaZOLAMIDE acetohexamide
buPROPion busPIRone
chlorproMAZINE chlorpropamide
clomiPHENE clomipramine
cycloSERINE cyclosporine
DAUNOrubicin DOXOrubicin
DOBUTamine DOPamine

16. USE GENERIC NAMES
GENERICNAME
POPULAR
BRAND
NAME
CIPROFLOXACIN CIFRAN
AMOXICILLIN
CLAVULANATE
POTASSIUM
AUGMENTIN
CARBAMAZEPINE ZEN
AMLODIPINE STAMLO

20. Packaging Design

21. PRESCRIBING TO INDIVIDUAL
PATIENTS
Allergies
Co-morbidities(especiallyliverandrenalimpairment)
Othermedication
PregnancyandBreastfeeding
Sizeofpatient

22. MEDICATION HISTORY
COLLECTION
•Name,dose,route,frequency,durationofeverydrug
•Over-the-countermedications,dietarysupplementsandalternative
medicines
•Druginteractions
•Medicationsthatcanbeceased
•Allergyhistory
•Medicationsthatmaybecausingside-effects

23. PRECAUTIONS FOR HIGH RISK MEDICINES
•Narrow therapeutic window
•Multiple interactions with others
•Potent medications
•Complex dosage and monitoring

24. KNOW THE MEDICATION
Pharmacology
Indications
Contraindications
Side-effects
Specialprecautions
Doseandadministration
Regimen

25. USE MEMORY AIDS
•Textbooks
•Personaldigitalassistant
•Computerprograms,computerizedprescribing
•Protocols

26. Five R’s
•Rightdrug
•Rightdose
•Rightroute
•Righttime
•Rightpatient

27. COMMUNICATE CLEARLY
•The 5 R’s
•State the obvious
•Close the loop

28. DEVELOP CHECKING HABITS
•When prescribing a
medication
•When administering
medication:
–Check for allergies
–Check the 5 R’s
•Unlabelledmedications
belong in the bin.

29. ENCOURAGE PATIENTS TO INVOLVE
IN PROCESS
•Providepatientswithalltheinformationaboutmedication.
•Tokeepawrittenrecordoftheirmedicationsandallergies.
•Topresentthisinformationwhenevertheyconsultadoctor.

30. REPORT & LEARN FROM MEDICATION
ERRORS
•Why?
•When?
•How?

31. SAFE PRACTICE SKILLS
•Prescribe,documentandadministermedication
•Usememoryaidsandperformdrugcalculations
•Performmedicationandallergyhistories
•Communicatewithcolleagues
•Involveandeducatepatientsabouttheirmedication
•Learnfrommedicationerrorsandnearmisses

32. STRATEGIES FOR IMPROVING
MEDICATION SAFETY
•Maintainuptodatereferences.
•Understandpatient’scondition,diagnosisandindicationsfor
medicationconsidered.
•Conditionsthatmayeffecttheefficacyofmedication(dosages,
routesofadministration,weight,renalandhepaticfunctioning).
•Understandpotentialinteractionsfornewandoldmedication.
•Recognizepotentialofriskofhighalertmediation.

33. HEALTH INFORMATION
TECHNOLOGY
•Maintainanactivemedicationallergylist.
•Maintainanactivemedicationlist.
•Usecomputerizedphysicianorderentryfor
medicationorders.
•Generateandtransmitelectronicprescriptionsfor
non-controlledsubstances.

34. 3 STEPS IN HOSPITALS
Medicationreconciliationprocess
Stepone–Verify
Steptwo–Clarify
Stepthree-Reconcile

38. The Dispensing Process
ReceivePrescription
InterpretPrescription
RetrieveMedication/Ingredients
PrepareandProcess
CommunicatewithPatient
AssurePatient'sUnderstanding
MonitorCompliancebyPatient
KeepRecords

39. Potential Error/Problems
Wronginterpretationofprescription
Noknowledgeofproperdrugcompliance
Wrongdosages
Insufficientknowledgeofthediseaseprocess
Insufficienttimetotalkwithpatientsabouttheirdrugs
Inabilitytocommunicatetopatientsabouttherapy

40. Why are MEs a problem?

41. What can be done?
Examinethevarioussystemsforcausesandimplement
change
Sharingourexperiencesthroughreporting
Presentationsinclinicalmeeting
PatientInvolvement&Communication

42. Responsibilities
Voluntaryselfreporting
Provideassistanceforhealthcareprofessionalsforthe
rightdispensingandsafeadministrationofdrugs.
Observationbasedstudies
Criteriabasedaudit
ReportErrorstoLocalauthorities

43. Role of Pharmacist
Unitdosedistributionsystem
Intravenousadmixturesystem
Computerprescriptionorderentrysystem
Barcodesystems

44. National Coordinating Council for
Medication Error Reporting