The Patient’s Role in Preventing

Medication Errors

Learning Objectives

• Discuss the patient’s role in preventing medication errors

• List ways in which health care professionals can assist patients in taking an active role in their medication therapy plan

Public Awareness of Medication Errors

• 1997 National Patient Safety Foundation survey: Public Opinion of Patient Safety Issues– Respondents believed carelessness and negligence

were the most frequent causes of errors

• The Institute of Medicine (IOM) reports brought public awareness of medication errors to a new level– To Err Is Human (2000)– Crossing the Quality Chasm (2001)

2004 Patient Awareness Study• 34% of respondents or a family member had been involved in

a preventable medication error• 52% and 36% believed the most important cause of errors

were mistakes by individual practitioners and institutions, respectively

• The lowest-ranked solution for preventing medication errors was medical malpractice law suits

• 70% believed medication error reports would provide valuable information they could use to compare hospitals

• Among patients taking precautions to reduce the risk of errors:• 69% reported checking the medication dispensed against the

physician’s prescription• 48% reported carrying a list of their medications with them

Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard School of Public Health. National survey on consumer’s experiences with patient safety and quality information. November 2004.

Health Care Providers Engaging Patients as Equal Partners

• To engage patients and families in their health care:– Make safety a top priority

– Connect with patients on a personal level • Listen to how medical stories and personal stories interact

– Include patients as an equal member in their own health care team by encouraging active participation in their care and in the decision-making process

– Earn patients’ respect by treating them with dignity and paying attention to the whole patient

– Strive to give patients what they want by actually asking them what they want

Health Care Providers Engaging Patients as Equal Partners

• To engage patients and families in their health care:– Improve adherence to a jointly developed plan of care by

providing good instructions• Even the most complex processes must be clear and easy

to follow

– Disclose errors — this may require changing the culture • Patients will not listen to us unless we begin to tell them

what we are doing about the problem of medication errors

– Offer emotional, physical, spiritual, and psychological support in the wake of a serious error

– Improve the efficiency and safety of our systems• Free our workforce to talk to patients and their families

Health Care Providers Engaging Patients as Equal Partners

• To engage patients and families in their health care:– Disclose all errors accompanied by:

• A fair offer of compensation for injuries through thoughtfully considering the financial burden placed on the victims of an error and sharing in that burden up front

– Motivate all patients to engage in their own health care and safety by providing them with the knowledge to fully participate

• Provide encouragement from programs such as the Speak Up: Help Prevent Errors in Your Care campaign from The Joint Commission

What Is the Patient’s Role?

Patients must know:• The questions to ask the health care provider• How to insist on answers• How to recognize situations that could produce

medication errors

Basic Questions Patients Need Answered

1. What are the brand and generic names of the medication?

2. What is the purpose of the medication?

3. What is the strength and dosage?

4. What are the possible adverse effects? What should I do if they occur?

5. Is there any other medication I should avoid while using this product?

6. I am allergic to _____. Should I take this medication?

7. How long should I take this medication? What outcome should I expect?

Basic Questions Patients Need Answered (continued)

8. When is the best time to take the medication?

9. How should I store the medication?

10. What do I do if I miss a dose?

11. Should I avoid any foods while taking this medication?

12. I’m also taking ____ (which I got at another pharmacy). Can I take both safely?

13. Is this medication meant to replace any other drug that I am already taking?

14. May I have written information about this drug?

The Answers Should…• Allow patients to take responsibility for safe drug use

• Be provided at the time the medication is prescribed — whether in a hospital or in the physician’s office — to be the most effective

• Provide a basis of information to build upon– Patients should have an information resource available, such

as a medication handbook or access to the Internet

• Be presented in a format and at a level that the patient can understand, and be reinforced periodically

• Encourage patients to question anything they do not understand or is not in keeping with their understanding

Five Steps to Follow When Picking Up a Prescription

1. Take the medicine out of the bag and read the label

• Are your name and your doctor’s name correct?

2. Read the directions on the label • Make sure that it is what your doctor told you, and that you

understand how much medicine to take and how many times a day you should take it

3. While you are still in the pharmacy, read the drug information sheet stapled to the bag to learn what the medicine is supposed to treat

• Is that what you are being treated for?

Five Steps to Follow When Picking Up a Prescription (continued)

4. Read about the possible side effects • If you are picking up a refill and realize you have been

having these side effects, tell the pharmacist immediately; the pharmacist may want to call your doctor

5. If you are getting a refill, make sure the medicine looks the same as it did last time; if it looks different, ask the pharmacist about it • Most likely, the pharmacist has filled your prescription with a

generic drug that looks different from what you are used to taking

Providing Instructions to Patients

• Do not assume patients understand directions

• Give clear and complete instructions, even about the routine parts of proper medication use– Example: A patient interpreted the label on a

coal tar preparation, “take four capfuls in bath” and proceeded to sit in the tub and swallow the coal tar solution meant for dilution in the bath water

Providing Instructions to Patients

The American Medical Association recommends six steps for improving communication with patients:

1. Slow down — speak slowly and spend a small amount of extra time with each patient

2. Use plain, nonmedical language

3. Show or draw pictures

4. Limit the amount of information provided, and repeat it

5. Use the teach-back or show-me technique

6. Create a shame-free environment

Patient Record Keeping

• Patients should keep updated records of all the medications and nonprescription products they are taking

• Information to be included in the records:– Name, strength, dose, and frequency of dosage of all

prescription medications

– Names of all nonprescription medicines, vitamins, and herbal products

• Herbals may affect the body and cause drug interactions

– Known allergies (medication or food)

– Special diets

– Medications that the patient previously took and the reason why the medication was discontinued

Patient Record Keeping

• Update medication list whenever medication regimen is changed

• Medication record-keeping forms are available from:– South Carolina Hospital Association

• Multilingual versions are available as well

– Institute for Safe Medication Practices • http://www.ismp.org/Newsletters/consumer/consumerAlerts.asp

Medication Packaging• Manufacturers may package their products in

containers that are virtually identical• Packaging and labeling may mislead users of a product

about the correct doses to take– Figure 13-2 in the textbook provides an example of ambiguous

packaging

• Dissimilar products can have similar packaging – Figure 13-3 in the textbook illustrates the similarity of eye

washes and respiratory therapy medications

• Mix-ups have occurred with products in containers resembling the containers often used for eye drops– Hemoccult solutions and other testing reagents often resemble

eye drops and have been instilled in the eye

Additional Information on Look-Alike, Sound-Alike

Medications and Packaging

Available in Slide Deck for Chapter 6

Error Potential With Brand Names and Extensions

• Not knowing the generic name could result in a patient taking both the brand and the generic doses of the same drug

• Different brand names may be used for the same drug when it is used to treat a different condition– Prozac for depression, Sarafem for premenstrual dysphoric

disorder

• There are no standard definitions of suffixes such as XL, SR, and ER

• Brand extensions allow manufacturers to keep a recognized brand name, but change the active ingredients

– Figure 13-5 in the textbook illustrates two Dulcolax products, one with bisacodyl as the active ingredient, one with docusate

Brand Names and Extensions

• The pharmacists’ and clinicians’ role:– Teach patients that each medication has one generic name

but may have one or more brand names – Provide patients both the generic and the brand name (if

applicable) – Emphasize the risk of duplicate therapy if the medication

prescribed is also marketed under other brand names– Provide patients with written instructions about which drug

previously taken at home is being replaced by a newly prescribed drug

– Encourage patients to properly dispose of discontinued medications

– Encourage patients to choose single-ingredient products

Readability of Labels

• Most medication packages have limited space for label information

• In 2002, the use of a new Drug Facts label format was required for almost all nonprescription products – Figure 13-6 in the textbook illustrates the information

and order of presentation on the label– The language is simple and the type size is larger

• Problems may arise with information put on a peel-away portion of the label, which might be overlooked or torn off

Readability of Prescribers’ Handwriting

• Patients should be able to clearly read all information on their prescriptions before leaving a physician’s office or hospital

• Patients should ask the prescriber to print or type drug names instead of writing in cursive

• Prescribers should indicate the purpose of the drug on the prescription • This reduces the likelihood of pharmacist

misinterpretation of “look-alike” drug names

Spoken or Phone Orders to Pharmacists

• The prescriber giving a spoken order to a pharmacist or nurse should be asked to spell the name of the drug

• The pharmacist or nurse taking the spoken order should write down the order and read it back to the caller

• Stating the purpose of the medication provides an additional safeguard

• Advise patients of the risks of spoken orders and ask them to minimize their requests for telephone prescriptions

• Faxed or electronic order entry and processing are preferable to telephone orders

Spoken Orders to Patients

• Patients are often instructed by telephone about changes in their medication regimens

• The directions on the prescription bottle may differ from the actual administration directions

• To reduce the risk of error, provide both: – The patient’s total dose in metric units– A description of the number of tablets needed for each

dose

Spoken Orders to Patients

• When patients are given orders by telephone, they should be asked to:– Retrieve a pen and paper to write any dosage

changes– Write the information as received and the date– Read back the dose and instructions to verify

understanding

• Advise patients to keep the dated instructions with the prescription bottle for quick reference

Spoken Orders: Misidentification

• Errors occur when patients are misidentified• The possibility of error can be reduced if:

– Patients insist on counseling before leaving the pharmacy

– Patients check to see that their name is on the label– Patients check to see that the name of the drug on

the label is the same as the drug name prescribed by the physician

• The patient’s address or date of birth may be incorporated into the method of identification

Medication Storage• Medications should be kept on a kitchen shelf or in a

linen closet — not in the bathroom– Moisture or heat and humidity may alter the effectiveness of

some medications– Medications may be confused for other common items

• Keep medications out of reach of children and pets• Do not leave medications in an automobile

– Extreme temperature variations may alter medications

• Care should be taken when using tablet organizers to avoid mix-ups between look-alike tablets

• Medications should not be stored in old medication bottles – Discard old prescription vials and never store multiple drugs in

the same container

Patient Nonadherence to Drug Therapy

• Nonadherence can be defined as any one of the following:– Not filling a prescription initially– Not having a prescription refilled– Omitting doses– Taking the wrong dose– Stopping a medication without the physician’s advice– Taking a medication incorrectly– Taking a medication at the wrong time– Taking someone else’s medication

Consequences of Nonadherence• Studies have found up to 93% of patients reporting

some form of nonadherence to medications 1,2

• Nonadherent patients are more likely to be hospitalized and require more clinic visits than adherent patients 3,4

• Nonadherence accounts for 10% of hospital admissions– 25% of hospital admissions among elderly patients

• Cost of nonadherence estimated to be $100 billion to $300 billion annually

1. Berg JS, et al. Ann Pharmacother. 1993;27:S5–S19.2. Greenberg RN. Clin Ther. 1984;6:592–8. 3. National Pharmaceutical Council. Noncompliance With Medications: An Economic

Tragedy With Important Implications for Health Care Reform. 1992.4. McGhan WF, et al. US Pharm. 2001;Impact suppl:1–13.

Consequences of Nonadherence

• A relationship exists between adherence and how important and desirable the outcome of treatment appears to the patient

• A patient is more likely to be nonadherent if he or she:– Takes more than one drug– Has a chronic condition– Takes a drug more than once a day– Has a condition that produces no overt symptoms or

physical impairment

Unintentional Nonadherence

• A patient may not intend to be nonadherent

• Reasons for unintentional nonadherence:– Patient suffers a visual impairment

– Patient does not understand the instructions for taking the medication

• Language barriers• Patient may not be literate

Reasons for Nonadherence: Knowledge Deficits

• Patient may lack knowledge about his or her medication and condition

• Language barriers may contribute to knowledge deficits

• Health care providers can help overcome this by:– Providing more information to the patient

– Presenting information in formats the patient can understand

– Having information professionally translated into the most commonly spoken languages

– Dispelling myths about treatment and disease

– Tailoring the information to the patient’s level of understanding

– Taking into consideration the patient’s cultural and ethnic background to tailor the presentation

Indicators of Limited Literacy• Health care providers need to be aware that:

– Knowledge deficits may not always be discernible– According to a 1993 National Adult Literacy Survey, nearly half

the U.S. population is marginally or functionally illiterate– Many people function well and have jobs even with low literacy– Many people hide their illiteracy, even from family– Some people with limited literacy rely on memory and color,

shape, or other cues instead of words– Some recent immigrants may use English as a second language– Some U.S.-born citizens use English as a second language

• See Table 13-1 in the textbook for indicators of limited literacy

National Center for Education Statistics. Executive summary of adult literacy in America: a first look at the results of the national adult literacy survey. August 1993.

Reasons for Nonadherence: Practical Barriers

• Practical barriers for nonadherence include:– Visual impairment

– Inability to pay or lack of insurance coverage

– Adverse drug reactions

– Confusing dosing schedules

– Difficult to open containers

– Cognitive impairment

Reasons for Nonadherence: Attitudinal Barriers

• Patient’s health care belief system formed by:– Culture – Ethnicity– Family– Personal values – Previous experience with the health care system

• Denial of their condition• Frustration with treatment• Lack of trust for the health care establishment

• Hospitalized patients

• Elderly patients

• Pediatric patients

Patient Populations Requiring Special Consideration

Hospitalized Patients

• Hospitalized patients are dependent on hospital personnel for safe drug use

• Patients are reluctant to ask questions for fear of being “troublesome”

• Patients need to take an active role – They should take their medication records and

medicines with them to the hospital, have them checked by a nurse or doctor, and then send them home with a family member

• Patients should ensure the nurse has read his or her armband before giving the medication

Hospitalized Patients

• Patients or a family member needs to ask the name and purpose of prescribed medication

• Before or at the time of discharge:– Take the opportunity to talk with a health care provider

about new prescriptions or changes to medications– Patients’ medication lists should be created or updated– Follow The Joint Commission medication reconciliation

process: • Complete medication list upon admission• Compare with medications subsequently prescribed• Upon transfer of care, communicate the medication list to

the next provider of service

Elderly Patients• Practitioners should be aware of the Beers criteria

– Beers criteria: identification of medications to avoid or use with caution in patients ≥65 years old

• Patient counseling should be done in a sensitive manner and with a family member or friend if possible

• A medication schedule for the patient is helpful; updates are essential for each medication change– Figure 13-8 in the textbook shows an example of a medication

schedule

• Use caution with pill organizers– Patients should be able to identify medications in case of spills

or changes to their prescriptions

Beers criteria in: Fick DM, et al. Arch Intern Med. 2003:163;2716–24.

Elderly Patients

• Keep medications in original containers• Ask questions at the time of prescribing;

prescribers may not be aware of a change in the dosage prescribed earlier

• Inquire about a dosage form of the medication that is easier to swallow if the patient is having difficulty

• Patients should check with a pharmacist before crushing or splitting a dosage form

Pediatric Patients

• Children may be reluctant to take medications because they do not know the difference between drugs that help and drugs that hurt

• Children with chronic illnesses may feel hopeless and become noncompliant

• Children have control over compliance with drug therapy in a world where they lack control over many other things

• Child-resistant packaging is necessary to reduce the risk of accidental poisoning in children

Pediatric Patients

• Adults should:– Safely store medications, with fastened caps, on a high shelf,

or in a locked box

– Never take their own medications while a child is watching

• The number for poison control should be posted near the telephone and pointed out to caregivers – Contact the Universal Poison Control number 1-800-222-1222

before attempting any home remedy

– Neither syrup of ipecac nor activated charcoal is recommended by the American Academy of Pediatrics for treating overdoses

Pediatric Patients

• Parents or caregivers should:– Mark the level of liquid medication after each use to

determine how much a child has accidentally ingested– When visiting another home, ask the host whether the

medications are stored in a place not accessible to children

– Caregivers should communicate with each other about when a child’s next dose is due

• Unit-dose packaging of oral solids makes it more difficult for children to accidentally ingest drugs

Resources for Patients

• ISMP Consumer Brochure – Available in the Appendix to Chapter 13 in the textbook– Provides:

• List of pertinent questions• Information about precautions patients can take at home• Information about what patients can do in the hospital

and the physician’s office

• Persons United Limiting Sub-standards and Errors in Healthcare (PULSE)– www.pulseamerica.org

• Consumers Advancing Patient Safety (CAPS)– www.patientsafety.org

References

Berg JS, Dischler J, Wagner DJ, et al. Medication compliance: a health care problem. Ann Pharmacother. 1993;27:S5–S19.

Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163:2716–24.

Greenberg RN. Overview of patient compliance with medication dosing: a literature review. Clin Ther. 1984;6:592–8.

Kaiser Family Foundation; Agency for Healthcare Research and Quality; Harvard School of Public Health. National survey on consumers’ experiences with patient safety and quality information. November 2004. Available at: http://www.kff.org/ kaiserpolls/pomr111704pkg.cfm.

References

Kirsch IS, Jungeblut A, Jenkins L, et al. Executive summary of adult literacy in America: a first look at the results of the national adult literacy survey. National Center for Education Statistics, U.S. Department of Education; August 1993.

Louis Harris and Associates. Public Opinion of Patient Safety Issues: Research Findings. Prepared for National Safety Foundation at the AMA. September 1997. Available at: http://www.npsf.org/download/1997survey.pdf.

McGhan WF, Peterson AM. Pharmacoeconomic impact of noncompliance. US Pharm. 2001;Impact suppl:1–13.

Task Force for Compliance. Noncompliance With Medications: An economic tragedy With Important Implications for Health Care Reform. Washington, DC: National Pharmaceutical Council;1992:1–16.