WHAT IS THE DEFINATION OF MEDICATION ERROR?

Medication Errors

The United States National Coordinating Council for Medication error Reporting and Prevention defines a

medication error as:

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, systems including:

prescribing; order communication; product labeling, packaging, nomenclature; compounding;

dispensing; distribution; administration; education; monitoring; and use.

Case Scenario-1A 1 week baby having 1.3kg in NICU

Resident doctor prescribed Inj. Meropenam (20mg/kg ) 30 mg IV 1-0-1 ( Dilute in 5ml NS, over 1 hour).

Nursing staff given first dose at 2am in the morning, and second should give at 2 pm in the afternoon but staff given 2nd dose at 6 am immediately after 4hours of 1st

dose.

Contributing factors:1. Staff not aware of drug timing protocols

2. Improper handover/communication among the staff

3. Cross check was not done by the senior staff

Case Scenario-2

IDDM, LGA, 4 kg weighted baby admitted in NICU

Doctor prescribed Inj. Vancomycin (10mg/kg/dose ) 80mg 1-1-1 .

R/N diluted 80mg in 5ml NS and given direct push instead of intermittent infusion. Immediately baby got anaphylactic shock and hypotension.

Immediately R/N informed to doctor and he advised to start inotropes and fluids.

Contributing factors:1. Incomplete prescription (Doctor not advised dilution

and rate of administration)

2. R/N not having an idea how to give antibiotics

3. Lack of communication

Types of Medication errors:

Prescription Errors

Transcription errors

Dispensing Errors

Administration errors

Monitoring Errors

Case Scenario-3

A pre term baby ( Wt- 1.09kg) having apnoea, doctor advised Inj. Caffeine citrate (10mg/kg )- 10mg over 30min.

Concern R/N administered the Inj. caffeine citrate 10mg but not signed in treatment sheet.

Contributing factors:1. Forgetfulness/Carelessness

2. Rushing to complete their task

3. Improper handover

Situations that contribute medication Error?

Inexperience staff

Staff rushing to complete their task

Doing two things at once

Failure of double checking mechanism

Poor communication and teamwork

Reluctance to use memory aids

Look alike, sound alike medications

Inadequate staff members

Absence of safety culture in work place

Case Scenario-4

• Ex 30 weeker, in NICU at corrected 34 weeks, on full feeds with relfux and inability to take full feeds by mouth, off IV

• Resident doctor prescribes Syp Domstal 0.3 ml 8 hourly.

• After 3 days, baby is getting domstal drops instead od Syp Domstal with dosing error

How to prevent medication Errors?

Category of Medication errorsTYPES OF ERRORS CATEGORY RESULT

NO ERROR Category A Circumstances or events that have the capacity to cause error

ERROR

NO HARMCategory B An error occurred but the medicine did not reach the patient

Category C An error occurred that reached the patient but did not cause patient harm*

Category D An error occurred that resulted in the need for increased patient monitoring

but no patient harm*

ERROR

HARMCategory E An error occurred that resulted in the need for treatment or intervention

and caused temporary patient harm*

Category F An error occurred that resulted in initial or prolonged hospitalization and

caused temporary patient harm*

Category G An error occurred that resulted in permanent patient harm*

Category H An error occurred that resulted in a near-death event (e.g. anaphylaxis,

cardiac arrest)

ERROR / DEATH Category I An error occurred that resulted in patient death

Follow the Rights of Medication Administration

1. Right Patient

2. Right Medication

3. Right dosage

4. Right Route

5. Right Time

6. Right Documentation

7. Right Patient Education

8. Right to Refuse

9. Right Assessment

10. Right Evaluation

What you can do to make medication use safer:

Use generic names

Tailor prescribing for each patient

Learn and practice through medication history taking

Know the high risk medications and take precautions

Know the medications you prescribe well

Use memory aids

Communicate clearly

Develop checking habits

Report and learn from errors