Medication Safety

Presented by Puan Rozita Mohamad, HOD of Pharmacy Department on Medication Safety Seminar

1. Jabatan Farmasi Institut Kanser Negara Medication Safety

2. Richard Smith, who had a history of kidney disease, had been admitted to the ICU after a dialysis session where he experienced severe shortness of breath. The next day, July 30, 2010, he complained of an upset stomach, so the doctor prescribed the antacid. The day his daughter came by to visit that morning, and found his dad "unconscious, unresponsive and on a respirator .“ "The nurse said my dad had coded. I said, 'He coded? When did that happen ?‘” The doctor told him, "I'm sorry to have to tell you this but the nurse administered the wrong medication and sent your dad into respiratory arrest .“ "He said the packaging looked the same and he grabbed the wrong package ,“ The nurse is wrongly given pancuronium instead of antacid. Upset stomach to code red

3. Medication error - definition “ 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. National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP, US)

4. To err is human: building a safer health system

5. Healthcare is nearly 10 years behind other industries in its efforts to reduce errors. Michael A. Jackson, BS Pharm, RPh Wesley G. Reines , PharmD

6. “MEDICATION ERROR : SIMPLE MISTAKE CAN BE LETHAL ” Medication Safety Is Everyone’s Responsibilities “PLEASE DO NO HARM”

7. Medication Error: Why the concern? The impact of medication safety incidents on patient outcomes includes increased length of stay, disability and mortality ( Vincent et al., 2001, UK ) Medication errors are estimated to account for at least 7,000 deaths in the United States alone every year. Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC : Institute of Medicine; 1999, p. 1 . Over 770,000 patients are estimated to be injured because of medication errors every year. Agency for Health Research and Quality, 2001 At least 1 death occurs per day and 1.3 million people are injured each year due to medication errors. Food and Drug Administration (FDA), US Medication error is one of the most common causes of unintentional harm in Australia which results in an estimated 80,000 hospital admissions every year ( Senator Kay Patterson, Federal Minister for Health and Ageing Australia, 9 September 2003)

8. Medication Error: Why the concern? Medication errors occur in nearly 1 out of every 5 doses given to patients in the typical hospital. ( Reference: Barker KN, Flynn EA, Pepper GA, PhD, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med 2002;162:1897-1903. ) One 5-year study showed that the most common types of medication errors were a wrong dose, a wrong drug or a wrong route of administration . ( Reference: Phillips J, Beam S, Brinker A, Holquist C, Honig P, Lee LY,Pamer C. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm. Oct 2001. 58(19);1835-41 ) Adverse medication events have been reported and are estimated to occur at a rate of around 5% for admissions and discharges from the typical hospital. ( Reference: Classen DC, Pestonik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. JAMA 1997; 277:301-306. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reaction in hospitalized patients. JAMA 1998; 279:1200-1205. ) Several studies point to more than 50% of potential and serious adverse events being associated with injectable medications. ( Reference: Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285:2114-2120. Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients: population based review of medical records. BMF 2000; 320:741-744. )

9. Medication Error: Why the concern? The extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year. This estimate does not take into account lost wages and productivity or additional healthcare costs "Preventing Medication Errors: Quality Chasm Series”, IOM Report , July 2006 IOM issued a report on the prevalence of medication errors in the United States in which at least 1.5 million Americans are injured every year by medication errors.

10. Martin A Makary , and Michael Daniel BMJ. 2016;353:bmj.i2139

11. Newspaper reports

12. Where can medication error occur? Medication error 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 ”

13. Medication Management Processes Errors Wrong Dose Wrong Drug Wrong Route/Form Allergy Drug Interaction Wrong Dose Wrong Drug Wrong Route Wrong Time Wrong Patient Wrong Dose Wrong Drug Wrong Route Wrong Time Wrong Patient Incorrect Labelling Primary Catch for allergy, drug interaction Wrong Dose Wrong Drug Wrong Route Wrong Time/ Omitted Wrong Patient Incorrect Labelling

14. Medication Safety Is Everyone’s Responsibilities The Pharmaceutical Services Division has always placed emphasis on medication safety and its strategies are in line with those of the Patient Safety Council of Malaysia Strategies to Improve Medication Safety Reporting & Learning Dissemination of Information Guidelines Education & Empowerment

15. Medication Error Reports Current medication error are reported to: United States Pharmacopeia ISMP Medwatch reports Manufacturer reports UK : National Reporting and Learning System (NRLS), National Patient Safety Agency (NPSA) Australia : NSW Health Incident Information Management System(IIMS) , Queensland Health Clinical Incident Information System ( PRIME CI) in Queensland Malaysia : MERS

16. Medication Error Reporting System (MERS)

17. Medication Error (ME) Reporting System (MERS) Purpose: T o obtain information on the occurrence of medication errors To maintain a database on medication errors To analyse the report To propose remedial actions and monitor the situations To minimize the reoccurrence of such errors

18. Number of ME Reports Received by Year

19. Process In Which The Error Occur

20. Contributing Factors of ME

21. Contributing Factors No of Reports Total Medication Related Look alike medication 317 1106 Look alike packaging 337 Sound alike medication 452 Staff Factors Distraction 3455 12003 Inadequate knowledge 2369 Inexperienced personnel 6179 Task & Technology Failure to adhere to work procedure 1647 3066 Illegible prescription 646 Incorrect computer entry 101 Patient information/record/ unavailable/ inaccurate 507 Use of abbreviations 165 Work & Environment Heavy workload 2566 8759 Peak hour 5492 Stock arrangements/ storage problem 260 Wrong labeling / instruction on dispensing envelope or bottle/ container 441

22. Error-Prone Abbreviation Abbreviation Intended meaning Common Error U Units Mistaken as a zero or a four (4) resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written. µg Micrograms Mistaken for "mg" (milligrams) resulting in an overdose. Q.D. Latin abbreviation for every day The period after the "Q" has sometimes been mistaken for an " I, " and the drug has been given "QID" (four times daily) rather than daily. Q.O.D. Latin abbreviation for every other day Misinterpreted as "QD" (daily) or "QID" (four times daily). If the "O" is poorly written, it looks like a period or "I."

23. Error-Prone Abbreviation Abbreviation Intended meaning Common Error SC or SQ Subcutaneous Mistaken as "SL" (sublingual) when poorly written. D/C Discharge; also discontinue Patient's medications have been prematurely discontinued when D/C, (intended to mean "discharge") was misinterpreted as "discontinue," because it was followed by a list of drugs. IU International Unit Mistaken as IV (intravenous) or 10(ten)

24. MMF – MTF HCT – HCTZ – HCQ CBZ – CPZ IVIg vs Human Albumin Error-Prone Abbreviation

25. How to prevent error? Use generic names for drug. Avoid trade names. Avoid using abbreviations Write clear instructions Daonil Glibenclamide X √ MTF Metformin X √ Gutt . CMC BD Gutt . CMC 2 drops RE BD X √

26. How to prevent error? Use leading zero before decimal point Avoid trailing zero after decimal point Avoid verbal orders Identify patient drug allergies .5 mg 0.5 mg X √ 5.0 mg 5 mg X √

27. Look Alike Sound Alike Medications (LASA) Medications that are: Visually similar in physical appearance or packaging Name of the medications that have spelling similarities

28. Inj. Vitamin K 1mg/ml Inj. Neostigmine Inj. Vitamin K 10mg/ml

29. Sound Alike Medications Clotrimazole – Co- trimoxazole Oxycontin - Oxynorm Dopamine - Dobutamine Adrenaline - Atropine Noradrenaline – Adrenaline

30. How to prevent error? Double checking the drug (dispensing/administering) (Pharmacist) Contacting the prescribers in case of any clarification regarding the prescription (DO NOT ASSUME) Becoming familiar with LASA medications Separating LASA medications from one another Using Tall Man Lettering Installing warning system to staff – Computer alerts or warnings on stock bottles

31. Separating LASA medications from one another

32. Extra Cautionary Labels

33. Tall Man Lettering No Medication No Medication No Medication No Medication 1 ATRA curium 13 DOBUT amine 25 LO sartan 37 PANTO prazole 2 BISO prolol 14 DOXO rubicin 26 LOVA statin 38 PERINDO pril 3 BUPI vacaine 15 DOP amine 27 met FORMIN 39 progy LUTON 4 car BAMAZ epine 16 Duph ASTON 28 METO prolol 40 Progy NOVA 5 car BIM azole 17 Duspa TALIN 29 NE ostigmine 41 Pro SCAR 6 cef OTAXi me 18 ENALA pril 30 Neuro BION 42 PRO zac 7 cef TAZID ime 19 ESOME prazole 31 Neuro NTIN 43 RO curonium 8 cef TRIAX one 20 FORT zaar 32 ni FED ipine 44 ROPI vacaine 9 chlorpro MAZINE 21 gli BEN clamide 33 ni MOD ipine 45 SETRA line 10 chlorpro PAMIDE 22 gli CLA zide 34 nitro GLYCERIN e 46 STELLA zine 11 CO zaar 23 LANSO prazole 35 nitro PRUSSID e 47 VE curonium 12 DAUNO rubicin 24 LIGNO caine 36 PAN curonium 48 vin BLAS tine

34. TALL MAN LETTERING

35. Dissemination of info

36. FENTANYL PATCH - HOW TO CUT Needs to be cut DIAGONALLY 6 MCG/HR 6 MCG/HR Only for 6mcg/ hr dose For 12mcg/ hr dose, use 25mcg/ hr patch (cut into half) 12 MCG/HR 12 MCG/HR

37. FENTANYL PATCH - HOW TO ADMINISTER 12 MCG/HR DOSE HOW TO ADMINISTER 6 MCG/HR FOR 3 DAYS ½ patch 12mcg/ hr 18 MCG/HR FOR 3 DAYS ½ patch 25mcg/ hr + ½ patch 12mcg/ hr 6mcg/ hr 6mcg/ hr 12mcg/ hr +

38. Guide On Handling Look Alike Sound Alike Medications

39. High Alert Medications (HAMs) Drugs that bear a heightened risk of causing significant patient harm when they are used in error . Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients . Institute for Safe Medication Practice (ISMP)

40. High Alert Medications (HAMs) … those that are most likely to cause significant harm to the patient, even when used as intended. … those medications with the highest percentage of, or potential for, medication errors and/or sentinel events and that carry a high risk for abuse, errors or other adverse outcomes. Institute for Healthcare Improvements (IHI) The Joint Commission (JCAHO)

41. Extra Cautionary Labels

42. Guideline on safe use of high alert medications

43. WHEN IT HAPPEN? Which one is less important? X Who? Why?

44. When a medication error occurs, organization wide system weaknesses are often identified in : How information is collected and communicated, How colleagues interact, How patients and staff are educated, How the organizational culture and physical environment are managed, How staff is provided to carry out patient care functions, How staff learns about system errors and their causes, and How patients are safeguarded from harm.

45. Patient information Drug information Communication related to medications Drug labelling, packaging & nomenclature Drug standardization, storage & distribution Medication delivery device acquisition, use, and monitoring Environmental factors Staff competency & education Patient education Quality processes & risk management Institute for Safe Medication Practices (ISMP) has listed down ten key elements that have the greatest influence on medication use :

46. Conclusion M edication error is common and is causing preventable human suffering and financial cost Remember that using medications to help patients is not a risk-free activity Interdisciplinary interactions go a long way toward preventing errors Know your responsibilities and work hard to make medication use safe for your patients

47. Guidelines available in moh

48. Thank you Pusat Maklumat Ubat @ Drug Information Centre, IKN Ext: 3434 or 3435 Unit Farmasi Klinikal Ext: 7114 or 7115

49. Medication label