medication errors

Medication Errors

Guided byDr. V. M. Motghare

Prof & Head Dept. of Pharmacology

Dr. Swarnank ParmarJR-2

Dept. of PharmacologyGMC, Nagpur 1

Overview

• Definition• Epidemiology• Classification• Causes of errors• Factors contributing & risks• Steps to prevent medication errors• Summary

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Definition

• “Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the health care professional, patient, or consumer”

• May occur at any time, from the prescription to consumption of the medicines by the patient

• Problems & sources of medication errors are multidisciplinary & multifactorial

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• Errors occur from-– Lack of knowledge– Unclear or erroneous labeling of drug – Misidentification of patient– Mental lapses or– Verification errors

• Errors committed by both experienced & inexperienced staff

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Epidemiology • Interesting but horrifying fact-

- More people in USA die in a given year as a result of medical errors than from motor vehicle accidents, breast cancers, or AIDS

• Majority are medication errors

• Indian study of paediatric intensive care unit reported 68.5% of all errors were medication errors

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• Reported epidemiology of this iatrogenic disease related to medication error- tip of the iceberg

• Numbers reported can be misleading due to- Small % of errors & adverse drug events detected,

even smaller number are reported Inconsistencies in way the errors reported & counted Most studies have looked errors only in inpatient

settings Most studies focus on errors of commission(fails to

consider errors of omission)

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Classification Errors

When actions are intended but not performed

Mistakes Errors in planning action

Skill based errors (slips & lapses)Errors in executing correctly planned

actions

1. Knowledge- Based errors

2. Rule- based errors

2a. Good rules not applied or misapplied

2b. Bad rules

3. Action-based errors (slips)

4. Memory-based errors(lapses)

3a. Technical

errors7

Intention

MistakesPlan cannot reach target

Intended

outcome

Slip/LapseError in

implementing plan

Check

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Sources of errors

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• Errors of Omission: errors related to prescription, drug dispensing by pharmacist, drug administration by medical personnel like nurses & patient themselves

• Errors of Commission: most common form of errors encountered in clinical practice, this include –

1.) Wrong phenomenon 2.) Drug interaction related 3.) Communication failure 4.) Failure to follow appropriate policies related to drug use 5.) Failure to follow drug-specific instructions 6.) Overuse of a drug(irrational drug use & polypharmacy)

Causes of errors

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1. “Wrong” phenomenon – - Wrong drug, wrong dose, wrong substitution for a

drug, wrong patient, wrong regimen, wrong route

2. Drug interaction related errors – - Food-drug interaction, drug- drug interaction or

interactions with other alternative forms of medicine - Responsible for medication errors, which may lead

to serious adverse events, sometimes hospitalization or death of patient

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3. Communication failure – - Failures during the process of patient

management - Includes illegible handwriting, incomplete

prescribing order, vague instructions, prescription not recognized & unknown prescriber

- Common errors include: ‘g’ mistaken for ‘mg’,

‘4’ mistaken for ‘U’, decimal point(‘.1’ read as ‘1’)

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• Some other recognized types of medication errors-

Incomplete patient information Drug information unavailable Miscommunication of drug orders Confusion in drug names Misuse of zeros & decimal points Confusion in dosing units Inappropriate abbreviations

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Swiss Cheese Model• Pictorial model for medication errors

• Defences against error displayed as thin layers with holes that describes latent errors in system

• Each layer successively represents the prescriber, pharmacist, nurse & patient related defences

• Missed error successively at various defence levels, reaches the patient

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Types of errors

• Prescribing errors

• Dispensing errors

• Administration errors

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Prescribing errors

Incorrect drug selection for

a patientErrors in

quantity & indication

Prescribing contraindicat

ed drug

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Factors contributing Lack of knowledge of the prescribed drug, dose,

patient details Illegible handwriting Inaccurate medication history taking Confusion with the drug name Inappropriate use of decimal points Use of abbreviations (e.g. AZT) Use of verbal orders

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Risk factors for prescribing errors

Work environment & workload

Miscommunication within team

Physical & mental well being

Lack of knowledge

Inadequate trainingLow perceived importance of

prescribingAbsence of self awareness of errors

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Reducing prescribing errors

• Electronic prescribing reduces errors due to illegible handwriting

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• Computerized physician order entry system eliminates need for transcription orders by nursing staff

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Dispensing errors

• Receipt of the prescription supply of a dispensed medicine to patient

• Occurs primarily with drugs having similar name or appearance

• Example :lasix® (frusemide) and losec® (omeprazole)

• Other potential dispensing errors include – wrong dose– wrong drug or– wrong patient

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Reducing dispensing errors• Ensuring a safe dispensing procedure

• Separating drugs with similar name or appearance

• Unit dose medication dispensing

• Automated medication dispensing system

• Bar code medications for dispensing & administration (patient given barcoded wristband)

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Administration errors• Discrepancy between drug received by patient

& drug therapy intended by prescriber

• Errors of omission - the drug is not administered

• Incorrect administration technique & administration of incorrect or expired preparations

• Deliberate violation of guidelines

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Contributing factors• Failure to check patient’s identity prior to

administration

• Environmental factors such a noise, interruptions, poor lighting

• Wrong calculation to determine the correct dose

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Reducing administration errors

• Checking patient’s identity.

• Ensuring dosage calculations are cross checked independently by another health

care professional before drug is administered

• Ensuring medication given at correct time

• Minimizing interruptions during drug rounds

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Drugs commonly associated with medication errors

• Analgesics-

– Unnecessary use of opioid analgesics (over sedation of patient)

– Errors reported are due to wrong route of administration

– Failure to monitor clinical parameters (heart rate, respiration & blood pressure), resulted in major adverse outcomes related to opioid use

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• Antibiotics- Irrational use

• Anticoagulants- Inadequate therapeutic dosing Failure to monitor blood levels

• Cardiovascular agents- Errors due to overdose Failure to identify drug-drug interactions due to

polypharmacy29

• Diabetic medications-– Overdose of hypoglycemic drugs (insulin)

– Overenthusiastic patients trying to keep blood glucose within normal limits

– Failure to take drugs in relation to meals

– This group of drugs signifies importance of patient education by treating physicians

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LOOK ALIKE SOUND ALIKE• Existence of confusing drug names is one of the most

common causes of medication error

• With thousands of drugs currently in market, potential for error due to confusing drug names is significant

• Contributing factors are – illegible handwriting,– incomplete knowledge of drug names– newly available products,– similar packaging or labelling– similar clinical use– Similar strengths, dosage forms, frequency of

administration 31

Major effect on therapeutic success

Brand name(Generic name)


Benzol (Danazol) Benzole (Albendazole)Alparazole (Alprazolam) Adprazole (Omeprazole)

Amsat (Ampicillin) Amset (Amlodipine)Adcom (Telmisartan) Adcon (Fluconazole)Alflox (Norfloxacin) Alfox (Oxcarbazepine)Dazolic (Ornidazole) Dazolin (Sertraline)

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Minor effect on therapeutic success



Aquamide (Furosemide) Aquazide (Hydrochlorthiazide)

Disprin (Aspirin 350mg) Dospin (Aspirin 75mg)Epitab (Phenytoin) Epitan (Phenobarbitone)

Ostofit (Glucosamine) Ostrobit (Ca. carbonate)Wormnil (Mebendazole) Wormonil (Albendazole)

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No significant effect on therapeutic success



Avcif (Cefixime) Avcip (Ciprofloxacin)

Atmox (Amoxicillin) Atrox (Roxithromycin)

Cefit (Cefixime) Cefiz (Cefpodoxime)

Ceftab (Cefuroxime) Ceftas (Cefixime)

Deplin (Sertraline) Depnil (Clomipramine)

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Strategies to prevent errors by LASA drugs

• Use of novel dosage delivery devices to distinguish products with similar names

• Print generic and brand names on unit-dose packaging, when possible

• Use of TALL MAN lettering to emphasize the spelling of drug names in medication storage areas (e.g. lamIVUDine & lamOTRIGine )

• Include dosing limits for medications with similar indications

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Steps to prevent medication errors

Targeted physician education on optimal medication use

Inclusion of clinical pharmacists in decision making activities

Computerized order entry by prescriber & medication checking

Standardize processes & equipment

Avoid use of unknown abbreviations & symbols

Double check patients having allergies before prescribing 37

Check the expiry date of the drug before administration

Medication Reconciliation

Standardised ordering and administration

Training, education, and organisational interventions

Preparing medicine in well lighted room

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Six step approach by WHO for good prescribing

• Evaluate & clearly define patient’s problem

• Specify therapeutic objectives

• Select appropriate drug therapy: P-drug & STEPS approach (Safety, Tolerability, Effectiveness, Price, Simplicity)

• Initiate therapy with appropriate details

• Give information, instructions & warnings

• Evaluate therapy regularly (e.g. Monitor treatment results)

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Role of regulatory authorities

• Important role in preventing medication errors

• Review of drug labels & nomenclature greatly enhances preventive strategies

• FDA provides guidance to industry to maintain proper drug labels

• Public education by regulatory agencies improves medication use

• Emphasis laid on having package insert in vernacular languages

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Role of organizations• Computer software installation by FDA to analyze

similar drug names

• Potentially confusing names rejected

• FDA reviews 300 brand names in a year before they are marketed to avoid confusion of LASA drugs

• FDA encourages pharmacists & other health professional to report any medication errors

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Role of prescribers• Doctors should have knowledge of generic names &

brand names of available drugs in their local setting

• Specify dosage form, drug strength & complete directions on prescriptions

• Using both brand name & generic name on prescription

• Purpose of medication

• Legible handrwiting

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Role of Pharmacist• Refer back to doctor if any confusion

• Basic knowledge of dosing regimens for commonly used drugs

• Computer reminder for serious confusing name pairs to avoid errors in prescription

• Stickers of ‘Alert’ in areas where LASA drugs stored

• In case of wrong prescription, pharmacist should not react in front of patient

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Role of nursing staff• Education & proper training important in reducing medication

related errors

• Most errors do not reach patient because of barrier role played by a nurse

• Independent calculations of paediatric doses by more than one person

• Should be aware of correct storage requirements for drugs

• Development of standardized dose & rate charts for products such as vasoactive drugs

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Patient & Physician education

• Regular short courses/training to junior residents by academic institution for good prescription writing practices

• Prescriber should also consider – – Age of patient– Any physical disability – Weak eye sight, before prescribing

• Patient educated regarding correct use of prescription & over the counter medicines

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• Patient should confirm name & strength of prescribed drugs before leaving doctor’s office

• Educated about the storage conditions of drugs (e.g. Insulin)

• Keeping medicines away from reach of children also should be emphasized

• Patient should carry all previous prescriptions to avoid repeating the drug or notice any change in prescriptions

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Summary

•Stay alert !•Question !

•Learn !

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Referneces • Medication Errors: Causes & its prevention, Singh

I, Shafiq N, Malhotra S;Drugs Bulletin Vol.XXXVI No. 2, April 2011

• British journal of clinical pharmacology;67:6, 2009

• Look alike & Sound alike drug brand names; Mukundraj S Keny, PV Rataboli; Indian journal of clinical practice, Vol. 23, no.9, February 2013

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medication errors

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