Rishabh Shukla 11.medication_errors.ppt..

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1. Social Pharmacy
and
Medication Errors.
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Premise:
Theappropriatemedication belongsto the
sphereofinterestofthe
pharmacoepidemiology asoneofthe
drugutilization
phenomenon.
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Medication errors
are receiving attention
in Social Pharmacy
because of importance
as well
among health care professionals
(pharmacists, physiciansand patients).
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Medication errorsoccur in all areas
of health care,
affecting all patient populations.
There are highlighted reports that medical
errors cause a large number of deaths
each year.
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Information production
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Medication error,
broadly definedas any error in the
prescribing,
dispensing,
or administrationof a drug,
irrespectiveof whether such errors leadto adverse
consequences or not, are the single most preventable
cause of patientharm.
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Medication error
is defined as any preventableevent 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.
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One of the difficulties
in this field is the variety of terms
used in the definition and classification of
medicationerrors.
A more recent definition of medication error as
afailure in the treatment process that leads to, or has
the potential to lead to, harm to the patient’ has recently
been proposed, along with a psychological approach to
the classification of medication errors according to
whether they are mistakes, slips, or lapses.
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10. Drug names can often sound
similar or appear similar.
In addition the appearance of the medicinal
products can look similar enough to cause
confusion.
SA Sound Alike Errors
LA Look Alike Errors
(LASA / SALA)
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Medication errorsmay be classified
according to the stage of themedication use
cyclein which they occur (prescribing,
dispensing, oradministration) although a
recent classification of medication error into
mistakes,slips, or lapses has been proposed.
Incidences of medication error rates vary
widely, as a result of the variety of different
study methods and definitions used.
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The majority of medication errors
occursas a result of poor prescribing
and ofteninvolve relatively
inexperienced medical staff, who are responsible
for the majorityof prescribing.
Electronic prescribing may help
reduce the risk ofprescribing errors owing to illegible
handwriting, although such systems can in turnlead to further
problems such as incorrect drug selection, and their effect on
patient outcomes requires further study.
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Medication errorscan occur
at any stage of themedication use process
and may or may notlead to anADE.
Depending on the setting, about one-thirdto
one-half of ADEs are associated with
medicationerrors.
The relationship between ADEs, potential ADEs,
and medication errors is shown in Figure 1.
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FIGURE 1:Relationship between ADEs,
potential ADEs, andmedication errors.
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INCIDENCE OF MEDICATION ERRORS
Incident rates of medication errors vary widely,
thereason for which can be explained by the different
studymethods and definitions used.
The rate of medication
errors varies between 2 and 14% of patients admitted to
hospital, with 1–2% of patients being harmed as
a result, and the majority are due to poor
prescribing.
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CLASSIFICATION OF MEDICATION ERRORS
The multiple steps in the medication chain,
fromwhenadrug is prescribed to whena patient receives the
drug,
lead to significant scope for error.
However, significantimprovements can be achieved from the
prevention ofmedication errors, in terms of reduced
patient morbidity,length of hospital stay, and
healthcare costs.
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CLASSIFICATION OF
MEDICATION ERRORS
Aclassification system based on a
psychological approachhas been
proposed which allows one to identify
broadcategories of error, quantifythem,
and develop anintervention to prevent
them.
This classification systemdivides errors
into mistakes, slips, or lapses (see Figure 2).
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FIGURE 2:The classification of medication errors
based on a psychological approach.
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Mistakes may be defined
as errors in the planning of anaction and may be
knowledge-based(e.g. giving amedication without having
established whether thepatient is allergic to that medication)
or rule-based.
Rulebasederrors can further be classified as
eitherthemisapplication of a good rule (e.g. injecting a
medicationinto the non-preferred site)
orthe application of a badrule or the failure to apply a good rule
(e.g. usingexcessive doses of a drug).
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Slips and lapses
are errorsinthe performance of an action –a slip through an
erroneous performance (e.g. writing the more familiar
‘chlorpropramide’ instead of ‘chlorpromazine’) and a lapse
through an erroneous memory (giving a drug that apatient is
already known to be allergic to).
Technicalerrorsare the result of a failure of a particular skill (e.g.
inthe insertion of a cannula) and are therefore a subset ofslips
(skill-based errors).
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Medication errorsmay also be
classified
according towhere they occur in
the medication use cycle,
i.e. at thestage of:
prescribing, dispensing, or
administrationof a drug.
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PRESCRIBING ERRORS
Prescribing errors may be defined as the
incorrect drugselection for a patient.
Such errors can include the dose,quantity,
indication, or prescribing of a contraindicated
drug.
Lack of knowledge of the prescribed drug, its
recommended dose, and of the patient details
contributeto prescribing errors.
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There are a lot of ways to reduce the medications errors and
depend on the pharmacist.
Strategies that pharmacists canuse to reduce medication errors
include:
1. Increase awareness of at-risk populations.
2. Avoid abbreviations and nomenclature.
3. Recognize prescription look-alike/sound-alike medications.
4. Beware of OTC family extensions and standardized labeling.
5. Focus on high-alert medications.
6. Look for duplicate therapies and interactions.
7.Do not take shortcuts around technology safeguards.
8. Report errors to improve process.
9. Control the environment.
10. Educate the patient.
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Other contributing factors include:
•Illegible handwriting.
• Inaccurate medication history taking.
• Confusion with the drug name.
• Inappropriate use of decimal points.A zero shouldalways
precede a decimal point (e.g. 0·1). Similarly,tenfold errors in
dose have occurred as a result of theuse of a trailing zero
(e.g. 1·0).
• Use of abbreviations(e.g. AZT has led to confusionbetween
zidovudine and azathioprine).
• Use of verbal orders.
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DISPENSINGERRORS
Dispensing errors occur at any stage of the dispensing
process,
from thereceipt of the prescription in the
pharmacy
to thesupply of a dispensed medicine
to thepatient.
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DISPENSINGERRORS
Dispensing errors occur at a rate of 1–24 % and
include selection of the wrong strength or medicinal
product.
Thisoccurs primarily with drugs that have a similar
name orappearance.
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SOME EXAMPLES
Lasix® (furosemide) and Losec® (omeprazole)are examples of
proprietary names which, when handwritten,look similar and
further emphasisethe need toprescribe generically.
Other potentialdispensing errors include
wrong dose, wrong drug, orwrong patient and the use of
computerisedlabellinghasled to transposition and typing
errors which are amongthe most common causes of
dispensing error.
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Approaches to reducing dispensing
errors include:
• Ensuring a safe dispensing procedure.
• Separating drugs with a similar name or appearance.
• Keeping interruptions in the dispensing procedure toa
minimum and maintaining the workload of thepharmacist at a
safe and manageable level.
• Awareness of high risk drugs such as potassiumchloride and
cytotoxic agents.
• Introducing safe systematic procedures for dispensing
medicines in the pharmacy.
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ADMINISTRATIONERRORS
Administration errors occur when a discrepancy occursbetween
the drug received by the patient and the drugtherapy intended
by the prescriber.
Drug administrationhas long been associated with one of the
highest risk
areas in nursing practice, with the ‘five rights’ (giving theright
dose of the right drug to the right patient at the righttime
by the right route) being the cornerstone of nursing
education. Drug administration errorslargely involveerrors of
omission where the drug is not administered fora variety of
reasons.
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DRUG ADMINISTRATION ERRORS
Other types of include an incorrect
administration technique andthe
administration of incorrect or
expiredpreparations.
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Electronic prescribing
Electronic prescribing may help to reduce the risk ofprescribing
errors resulting from illegible handwriting,although it can in
turn lead to further problems such asincorrect drug selection.
Computerised physician orderentry
systems
eliminate the need for transcription oforders by nursing staff and
for interpretation of orders bypharmacy staff and have been
shown to have a significanteffect
on reducing medication errors.
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Causes of administration errors
included a lack of perceived risk, poor role models, and lackof
available technology.
Mistakes tended to occur whendrug preparation or
administration involved uncommonprocedures with causes
including a lack of knowledge ofthe preparation or
administration procedures and thecomplex design of
equipment.
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Contributing factors to
drug administration errors
include a failure to check the patient’s identity prior to
administration and the storage of similar preparations in
similar areas. Environmental factors such a noise,interruptions
whilst undertaking a drug round, andpoorlighting may also
contribute to these errors.
Thelikelihood of error is also increased where
more than onetablet is required to supply the
correct dose or where acalculation to
determine the correct dose is undertaken.
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Approaches to reduce
drug administration errors include:
•Checkingthe patient’s identity.
• Ensuringthat dosage calculations are checkedindependently
by another health care professionalbefore the drug is
administered.
• Ensuringthat the prescription, drug, and patient are inthe same
place in order that they may be checkedagainst one another.
• Ensuringthe medication is given at the correct time.
• Minimisinginterruptions during drug rounds.
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Pharmacists are key
to ensuring the safe use ofmedicines
and the current system whereby wards are
visited daily by pharmacists places them in a
goodposition to recognise particular training
needs that can beaddressed.
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Finally,
an alternative approach to reducing medicationerrors is
to target high alert drugs and procedures.
Theimplementation of a carefully planned series of
low-costinterventions focused on high-risk
medications, driven by
information derived largely from internal event
reporting,and designed to improve a hospital’s
medication safety,have
been shown to significantly reduce patient harm as a
resultof medication errors.
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Drugs which have been identified
ashaving a high potential for error include:
potassium chloride,
high strength narcotics,
cancer chemotherapy,
heparin,
insulin,
vasoactive drugs, and epidural infusions.
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Design issues
such as ampoules that look similarand the complex design of
infusion pumps have beenrecognised as risk factors for
intravenous administrationerrors and puts the onus on
manufacturers to supplyproducts to a high safety standard.
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It has been suggested
that the pharmaceutical industrycould apply a framework of
human error theory at theproduct design stage
and include consultations withhealth care professionals –
pharmacists
who will be dispensingand using their product.
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The licensing process
could also consider any differences
between the productused in clinical trials and that used
in clinical practice and the
medication error potential of aparticular
product
should be formally assessed during the
post-marketing surveillance process.
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CONCLUSIONS
All healthcare professionalshave a responsibility
inidentifying contributing factors to
medication errors and
to use that information to further reduce their
occurrence.
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CONCLUSIONS
A multidisciplinary approach to solving the
problem of medication errors needs to be taken.
Significant increases in the reporting of
medication errorshave been noted where
confidential, no-fault reporting has
been implemented.
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CONCLUSIONS
• Medication errors are one of the most preventable causes of
patient injury although the incidence of such errors varies
widely as a result of differing definitions and
methodologies.
• The majority of medication errors occur as a result of poor
prescribing, emphasising the need to improve prescribing
skills.
• The problems, sources and methods of avoiding medication
errors are multifactorial and multidisciplinary.
• A non-punitive approach should be adopted to improve the
rate of reporting of medication errors, allowing further
investigation of these important causes of preventable
patient harm.
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Creating a culture of safety
doesnotjust mean eradicating the culture of blame but also
involveschanging the entire way one thinks about and
approachesthe work in the medication cycle.
Whilst it may seemcounterintuitive to reward people for
reporting failures,this is what is required in order to create a
culture ofsafetyin order that one can understand
what causesmedication errorsand
implement systems to prevent them recurring.
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Thanks for your attention.
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