Medication errors ppt

Medication Error are the most preventable events and Clinical Pharmacists can play a vital role in preventing them. in this presentation i have tried to provide maximum information regarding medication error in minimum slides.

1. Medication Errors By: Dr. Ankit Gaur ( B.Pharm , M.Sc , Pharm.D , RPh )

2. 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. 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."

3. FACTORS CONTRIBUTING TO MEDICATION ERRORS • Human-related • System-related • Medication-related Near Miss (Medication Error): Medication error that took place but captured before reaching to the patient. Such events have also been termed as ‘near miss’ Medication error.

4. Human-Related Factors Providers Over-worked Under-trained Competence Distracted Illness Stressed Patients In a hurry Health literacy level Do not understand the medication/use Trust providers to not make mistakes

5. System-Related Factors Lack of communication Poor workflow Disorganized workspace Inadequate tools to complete work Lack of supervision  

6. Medication-Related Errors Look-alike/sound-alike medications Multiple dosage forms and strengths  

7. THE 6-R ’ S Right Drug Right Route Right Time Right Dose Right Patient Right Dosage Form World Health Organization WHO, Patient Safety Curriculum Guide

8. Types of Medication Errors Medication errors include Prescribing Error Dispensing Error Documentation Error Administration Error Transcription Error Indent Error

9. Prescribing error: A clinically meaningful prescribing error occurs when, as a result of a prescribing decision or prescription writing process, there is an unintentional significant (1) reduction in the probability of treatment being timely and effective or (2) increase in the risk of harm when compared with generally accepted practice” . It includes: Incorrect Prescription Illegible Handwriting Drug allergy not identified Irrational combinations Out of list abbreviations

10. Dispensing Error A  dispensing error  is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient or distributes to the ward on the basis of this prescription, including the  dispensing  of a medicine with inferior pharmaceutical or informational quality 

11. Dispensing Errors: The Numbers 98.3% accuracy in dispensing medications Therefore, 1.7% inaccuracy rate Over 3 billion medications dispensed per year 4 errors per day per 250 prescriptions filled Over 51 million dispensing errors per year Flynn E, et al. J Am Pharm Assoc. 2003;43:191 – 200.

12. Most Prevalent Dispensing Errors Dispensing incorrect medication, dosage strength, or dosage form Dosage miscalculations Failure to identify drug interactions or contraindications

13. http://www.patientensicherheit.ch/de/publikationen/Quick-Alerts.html Sound alike and look alike drug names Generic name Trade name Clonidin Catapresan Clomipramin Anafranil Codein Codein Knoll Etodolac Lodin Cotrimazol Bactrim , Cotrim , Nopil Clotrimazol Canesten , Corisol

14. Errors of Omission Failure to counsel the patient Failure to screen for interactions and contraindications

15. Errors of Commission Miscalculation of a dose Dispensing the incorrect medication, dosage strength, or dosage form

16. Dispensing Errors: Common Causes Work environment Workload Distractions Work area Use of outdated or incorrect references LASA drugs (Look Alike Sound Alike)

17. Example of dispensing error A physician writes an order for primidone ( Mysoline ) for a 12-year old boy with a seizure disorder. Misreading the physician’s handwriting, the pharmacist mistakenly fills the order with prednisone. For 4 months, the boy receives prednisone along with his seizure medications, causing steroid-induced diabetes. The diabetes goes unrecognized, and he dies from diabetic ketoacidosis …because the drug was LASA drug that lead to Dispensing Error

18. Poor Communication Dynamics From a Published Reference

19. Ambiguity in Written Orders

20. Administration Error: A drug administration error may be defined as a discrepancy between the drug therapy received by the patient and the drug therapy intended by the prescriber. Administration errors account for 26% to 32% of total medication errors. It involved wrong patient, wrong route of administration, wrong drug, wrong dose, wrong method, wrong time.

21. CAUSES OF ADMINISTRATION ERRORS: Lack of perceived risk Lack of available technology Lack of knowledge of the preparation or administration procedures Complex design of equipment. CONTRIBUTING FACTORS TO DRUG ADMINISTRATION ERRORS: Failure to check the patient’s identity prior to administration Environmental factors such a noise, interruptions ,poor lighting Wrong calculation to determine the correct dose

22. Example of administration error A critical care nurse tries to catch up with her morning medications after her patient’s condition changes and he requires several procedures. He is intubated , so she decides to crush the pills and instill them into his nasogastric (NG) tube. In her haste to give the already-late medications, she fails to notice the “Do not crush” warning on the electronic medication administration record. She crushes an extended-release calcium channel blocker and administers it through the NG tube. An hour later, the patient’s heart rate slows to asystole , and he dies…because of Administration error

23. Transcription Error Transcription is a process of making an identical copy of prescription in the medical records. Error that occurs during this process is known as Transcription Error. Several sheets of paper and stages from physician’s order to drug delivery may cause confusion and add to the possibility of transcription errors. Contributing factors include incomplete or illegible prescriber orders; incomplete or illegible nurse handwriting; use of abbreviations; and lack of familiarity with drug names. In addition to errors associated with transcribing the drug name, there is also opportunity for errors when transcribing the dose, route or frequency.

24. Indent Error Error that occurs during the process of indenting It includes wrong drug, wrong strength, Wrong dose, Wrong route and frequency.

25. Categorization of medication Errors: Category Event A Circumstances or event that has a capacity to cause error. B Error occurred but didn’t reach the patient. C An error occurred that reached the patient but did not cause any harm. D An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and /or required intervention to preclude harm. E An error occurred that may have contribute to or resulted in temporary harm to the patient and required intervention.

26. Category Event F An error occurred that may have contribute to or resulted in temporary harm to the patient and required transfer to other unit/critical care. G An error occurred that may have contribute to or resulted in permanent harm of the patient. H An error occurred that required intervention to sustain life. I An error occurred that may have contribute to or resulted in patient.