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Medication Safety _amp; Medication Errors PHCL 311 Lecture 1

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Medication Safety _amp; Medication Errors PHCL 311 Lecture 1 Powered By Docstoc
					Medication Safety &
Medication Errors
          Part I
      PHCL 311
   Hadeel Al-Kofide MS.c
         Topics to be covered today
• Introduction

• The evidence that medication error is a problem

• Definitions

• The relationship between medication error, ADE & ADE

• Classifications & types of medication error

• Reasons for medication errors

• How to prevent medication error
                     Introduction
• The goal of drug therapy is the achievement of defined
  therapeutic outcomes that improve a patient’s quality of life
  while minimizing patient risk

• With every therapy there must be a risk, it could be known or
  unknown

• These risks are defined as drug misadventures, which includes
  both adverse drug reactions (ADRs) & medication errors
                     Definitions
• Medication error

• Adverse drug event (ADE)

• Adverse drug reaction (ADR)
Definitions

              Adverse Drug Events (ADE)
      • Any injury caused by a medicine or lack of intended
        medication

           Adverse drug reactions & overdoses

           Dose reductions & discontinuations of drug therapy
Definitions

              Adverse Drug Reaction (ADR)
      • Any unexpected, unintended, undesired, or excessive response
        to a drug, with or without an “injury”

      • Harm directly caused by the drug at normal doses,
        during normal use
Definitions

                 Medication Error (ME)
      • Any preventable event that has the potential to lead to
        inappropriate medication use or patient harm during
        prescribing, transcribing, dispensing, administering,
        adherence, or monitoring a drug

      • Medication errors that are stopped before harm can occur are
        sometimes called “near misses” or more formally,
        a potential adverse drug event
        The Relationship Among ME, ADEs, &
                        ADRs




                                              Medication
                                              Errors                                  ADEs
                                                                               ADRs




Nebecker et al. Ann Intern Med 2004;140: 795-801, J Gen Med 10:199-205,1995.
What Is The Evidence That Patient
      Safety Is A Problem?
ME is A Problem


             Evidence That ME is A Problem
      • Medications harm at least 1.5 million people per year

      • 44,000 to 98,000 hospitalized Americans die each year from
        medical error

      • Errors cause more death each year than breast cancer, motor
           vehicle accidents & AIDS




Institute of Medicine. Preventing medication errors: quality chasm series, 2006
ME is A Problem


            Evidence That ME is A Problem
     • The financial burden from these medical errors that is
       estimated to be in a range of $30 billion to $130 billion
          annually

     • Up to 28% of these events are thought to be preventable




White TJ et al, Pharmacoeconomic. 1999, Classen DC et al, JAMA. 1997
ME is A Problem


       Medication Error Deaths Increasing

                           Deaths from
                           Medication Errors




                 1983                                  1998


Phillips DP. Annu Rev Public Health. 2002;23:135-50.
Types & Classification of
  Medication Errors
      Types & Classification of ME
• NCC MERP index for categorizing medication errors

• Medication use process

• Three major areas for medication error:

    Prescribing

    Dispensing

    Administration
NCC MERP Index for Categorizing Errors
Medication Safety &
Medication Errors
         Part II
      PHCL 311
   Hadeel Al-Kofide MS.c
    Topics to be covered last lecture
• Introduction

• The evidence that medication error is a problem

• Definitions

• The relationship between medication error, ADE & ADE

• Classifications & types of medication error

• Reasons for medication errors

• How to prevent medication error
         Topics to be covered today
• Focusing on error prevention

• Identifying medication error

• How to approach error (Person Vs. System)

• Methods used to minimize or reduce medication errors

• Establishing a culture of safety (Building a safer healthcare
  system )

• Medication error reporting system
                   The Medication Use System
                   High-Level Portrayal of a Medication Use System


     Selection &         Prescribing        Preparing &        Administering       Monitoring
     Procuring           Assess patient;    Dispensing         Review              Assess patient
     Establish           determine need     Purchase &         dispensed drug      response to
     formulary
                         for drug           store drug;        order; assess       drug; report
                         therapy; select    review &           patient &           reactions &
                         & order drug       confirm order;     administer          errors
                                            distribute to
                                            patient location



   Clinician &           Physician/                                             All
                                           Pharmacist          Nurse/other
   administrators        prescriber                                             practitioners,
                                                               health
                                                                                plus patient
                                                               professionals
                                                                                &/or family
Joint Commission. 1998
  Major Areas for Medication Error
• Medication errors can be broadly classified as

    Prescribing

    Dispensing

    Drug administering errors
         Major Areas for Medication Error



                              38%                39%


                                     12%   11%




Medication Errors Reporting Program US
Types of ME


                          Prescribing Errors
     • It is an incorrect drug selection for a patient. Such errors can
       include the dose, strength, route, quantity, indication, or
       prescribing contraindicated drug

     • This definition can be further expanded to include failure to
       comply with legal requirements for prescription writing




Williams DJ. 2007,
Lesar et al. JAMA. 1997
Types of ME


                       Prescribing Errors
     Contributing factors:

     • Illegible handwriting

     • Inaccurate medication history taking

     • Confusion with the drug name

     • Inappropriate use of decimal points

     • Use of abbreviations (e.g. AZT has led to confusion between
       Zidovudine & Azathioprine)

     •     Use of verbal order

Williams DJ. 2007
Prescribing Errors….. Examples
          Name That Drug…




       Lipitor 10mg PO QD


         Filled Rx: Zyrtec 10mg
Prescribing Errors….. Examples
           Name That Drug…




    6 unties of regular insulin now

            Filled Rx: 60 units
Prescribing Errors….. Examples
           Name That Drug…




       Tegretol 300mg BID

      Filled Rx: Tegretol 1300mg
Prescribing Errors….. Examples
                  Name That Drug…




Filled Rx: Coumadin 2mg PO HS & Coumadin 4mg PO
QAM           Cardura 2mg PO HS &
               Avandia 4mg PO QAM
Patient received 6mg of Coumadin PLUS no treatment for
hypertension & diabetes
  Prescribing Errors…..Examples
Sometimes the technology itself is the problem…




    Monopril 40mg

   Filled Rx: Monopril 10mg
                 Dispensing Errors
• It is an error that occurs at any stage during the dispensing
  process from the receipt of a prescription in the pharmacy
  through to the supply of a dispensed product to the patient

• Studies have estimated that dispensing errors occur at a rate of
  1-24%

• These errors include the selection of the wrong
  strength/product. This occurs primarily when ≥ 2 drugs have a
  similar appearance or similar name (look-a-like/sound-a-like
  errors)
Dispensing Errors…..Examples
Dispensing Errors…..Examples
Dispensing Errors…..Examples
     Dispensing Errors…..Examples


Rx

AXERT (almotriptan) 6.25 mg 1-2 tablets at once, & repeat in
              2 hours if needed up to 25 mg/day


Dispensed

ANTIVERT (meclizine)
Dispensing Errors…..Examples


Rx

Keppra (anticonvulsant) 500 mg every 12hours


Dispensed

Kaletra (antiviral)
            Administration Errors
• Defined as a discrepancy between the drug therapy received by
  the patient & the drug therapy intended by the prescriber

• Drug administration is associated with one of the highest risk
  areas in nursing practice
             Administration Errors
• Drug administration errors largely involve errors of omission
  where administration is omitted due to a variety of factors e.g.
  wrong patient, lack of stock

• Other types of drug administration errors include wrong
  administration technique, administration of expired drugs &
  wrong preparation administered
                      Administration Errors
     Contributing factors:
     • Failure to check the patient’s identity prior to administration
     • Storage of similar preparations in similar areas
     • Noise, interruptions while undertaking a drug round, & poor
          lighting
                         • More than one tablet for a single dose
     •       Errors      • Calculation is required to determine the
                         correct dose




Williams DJ. 2007
Administration Errors…..Examples
     A patient had an epidural line for pain management & a
                peripheral IV line containing insulin



    The nurse caring for the patient was busy & asked a second
     nurse to retrieve the next scheduled epidural infusion bag

    The second nurse delivered a new bag of insulin to the
     patient’s bedside
    Without checking the label, the primary nurse hung the insulin

    infusion to the epidural line
    Reasons For Medication Errors
1. Ambiguous strength           5. Improper transcription &
   designated on labels or in      inaccurate dosage
   packaging                       calculation

2. Drug product nomenclature    6. Inadequately trained
   (look-alike or sound-alike      personnel
   names, use of lettered or
                                7. Inappropriate abbreviations
   numbered prefixes &
   suffixes in drug name)       8. Labeling errors

3. Equipment failure or         9. Excessive workload
   malfunction
                                10. Lapses in individual
4. Illegible writing                performance
                                11. Medication unavailable
Focusing on Error Prevention
Can We Do Anything About These
           Errors?



       Step One
       See the problem
Can We Do Anything About These
           Errors?
           Step Two


          Identify
          The Risk
        & Manage It
Identifying Medication Error
      How Can We Identify The Risk?
• High alert medication

• Error prone notations

• Look-a-like & sound-a-like medications
           High Alert Medications
• What are high alert medications?

• How can we reduce the error associated with high alert
  medications?
High Alert Medications

            "Top 10" Medications Involved in Drug
                          Errors

                    Agent             % of Drug Errors Associated with
                                            Acute Hospital Care

                     Insulin            4% of all medication errors in 2005

                   Morphine                           2.3%

             Potassium Chloride                       2.2%

                   Albuterol                          1.8%

                    Heparin                           1.7%


    United States Pharmacopeia.2007
High Alert Medications

            "Top 10" Medications Involved in Drug
                          Errors

                    Agent             % of Drug Errors Associated with
                                            Acute Hospital Care

                 Vancomycin                         1.6%

                   Cefazolin                        1.6%

               Acetaminophen                        1.6%

                    Warfarin                        1.4%

                  Furosemide                        1.4%


    United States Pharmacopeia.2007
High Alert Medications
        Strategies To Reduce Risk From High-
                   Alert Medications
     • Limit the access to these medications

     • Standardizing the ordering/preparation & administration

     • Independent double check at dispensing & administrating
       phase
             Error-Prone Notations
• Ambiguous medical notations are one of the most common &
  preventable causes of medication errors

• Misinterpretation may lead to mistakes that result in patient
  harm

• Delay start of therapy due to time spent for clarification
Error Prone Notations


               Implement “Do Not Use” List
     • ISMP & FDA recommend that ISMP’s list of error-prone
       abbreviations be considered whenever medical information is
       communicated



              Complete list is located at:

              www.ismp.org/Tools/errorproneabbreviations.pdf




                                             ISMP= Institute for Safe Medication Practices,
                                             FDA= Food and Drug Administration
Error Prone Notations


          Short List of Error-Prone Notations*
                             Notations should NEVER be used

                Notation                           Reason            Instead Use
                        U                   Mistaken for 0, 4, cc         Unit


                     IU                    Mistaken for IV or 10          Unit


                     QD                      Mistaken for QID            Daily


                  QOD                   Mistaken for QID, QD        “every other day”



   * Comprises “Do Not Use” list required for JCAHO accreditation
Error Prone Notations


          Short List of Error-Prone Notations*
                             Notations should NEVER be used

                 Notation                             Reason            Instead Use
            Trailing zero (X.0                Decimal point missed         “X mg”
                     mg)
              Naked decimal                   Decimal point missed        “0.X mg”
               Point (.X mg)
                        cc                        Mistaken for U            “mL”


                   MS                     Can mean Morphine Sulfate   “Morphine Sulfate”
                                           or Magnesium Sulfate

   * Comprises “Do Not Use” list required for JCAHO accreditation
Error Prone Notations


          Short List of Error-Prone Notations*
                                Notations should NEVER be used

                 Notation                             Reason            Instead Use
                       > or <                Mistaken as opposite of   “greater than” or
                                                       intended           “less than”
                         μ                       Mistaken for mg           “mcg”


                        @                          Mistaken for 2            “at”


                   /                             Mistaken for 1             “per”



   * Comprises “Do Not Use” list required for JCAHO accreditation
Error Prone Notations


          Short List of Error-Prone Notations*
                             Notations should NEVER be used

                 Notation                             Reason         Instead Use
                        +                          Mistaken for 4         “and”


                D/C, dc, d/c            Misinterpreted as when         “discharge”
                                        “discontinued” followed by         or
                                        list of medications          “discontinued”




   * Comprises “Do Not Use” list required for JCAHO accreditation
Error Prone Notations


      Error-Prone Notations…..Examples




                        Intended dose of 4 units


                           Administered 44 units
                           Should be written as “4 units”
Error Prone Notations


      Error-Prone Notations…..Examples




                        Intended dose of “.4 mg”


                            Administered 4mg
                            Should be written as “0.4 mg.”
Error Prone Notations
          Strategies To Reduce The Risk From
                 Error Prone Notations




                   • NEVER use notations
Approaches to Reduce Medication
            Errors
     Approaches to Reduce Medication
                 Errors
• Person-centered approach

• System centered approach

• The Swiss cheese model of systems errors
     Approaches to Reduce Medication
                 Errors
 Person-Centered Approach

• It has been traditional used in analysis of medication errors

• It looks at medication errors as occurring due to human frailty,
  including

                  Forgetfulness

                 Poor motivation

                 Carelessness, not paying attention

                 Negligence
     Approaches to Reduce Medication
                 Errors
 System-Centered Approach

• Errors expected to occur

• Errors are viewed as the end result & not the cause

• There is potential for error & recurring errors in every system,
  & even the best systems fail
     Approaches to Reduce Medication
                 Errors
 System-Centered Approach

• Solutions are based on the belief that conditions can be
  changed, rather than focusing on changing humans

• Barriers & safeguards should be implemented to help prevent
  errors

• It is essential to focus on how & why the system failed & not
  on which individual failed
Methods Used to Minimize or
 Reduce Medication Errors
       Reducing Medication Error
• Steps to minimize medication error

• Prescriber actions

• Pharmacy (dispensing) actions

• Nurse (administrator) actions
Steps to Minimize Medication Error
  Most
effective




  Least
effective
Steps to Minimize Medication Error
Forcing functions & constraints

• Use pharmacy system that will not fill any order unless allergy
  information, patient weight & height are entered

• Use computer order entry with dosage checks

• Remove dangerous IV drugs (e.g. conc. potassium, hypertonic
  sodium chloride) from ward stock

• Limit choices of available drugs in pharmacy

• Limit dosage strengths & concentration for each drug

• Mix IVs in the pharmacy
Steps to Minimize Medication Error
Automation & computerization (Reduce reliance on memory)

• Use drug-drug interaction checking system

• Use computerized order entry

• Use computerized patient information

• Use bar-coding on drugs, containers, medication records,
  patient wristbands

• Automated dispensing on patient care unit
Steps to Minimize Medication Error
Standardization & protocol

• No error –prone abbreviations

• Use generic names rather then brand name

• Use standard equipment—one kind of pump or syringe

• Use protocol for complex medication administration e.g.
  heparin, chemotherapy
   Prescriber Action to Reduce ME
• Stay current & knowledgeable concerning changes in
  medication & treatment
• Utilize pharmacist consultation if available
• Ensure that drug orders are complete, clear, unambiguous &
  legible
    Including patient weight, dosage (mg/kg/dose or/day), frequency &
     route of administration
    Avoid use of terminal zero e.g. use 5 rather 5.0
    Use a zero to the left of a zero ( use 0.2 rather .2 )

• Discuss medication changes with nursing & other staff &
  families
    Pharmacy Action to Reduce ME
• Independent double check orders both on calculation &
  preparation

• Clarify confusing orders

• Checking for current patient drug allergy

• Dispense medication using unit-dose, ready to administration
  form whenever possible

• Patient name, generic drug name, patient specific dose on all
  labels
      Nursing Action to Reduce ME
• Double check medication calculations

• Verify drug order & confirm patient identity & weight before
  administration

• Have access to drug information on all medications

• Familiar with the operation of medication administration
  device
Medication Error Reporting
         Systems
Medication Error Reporting System
• International systems

• National system

• Local (in hospital or healthcare setting) system

• No system
            International Systems
• The Medication Error Reporting Program operated by United
  States Pharmacopoeia in cooperation with the ISMP

• The Joint Commission on Accreditation of Healthcare
  Organization (JCAHO) sentinel event reporting system

• The FDA MedWatch program

• MEDMARX®

• The National Coordinating Council for Medication Error
  Reporting and Prevention (NCC MERP)
                Pharmacovigilance
• Data gathering related to the detection, assessment,
  understanding, and prevention of adverse events

• Identifying new information about hazards associated with
  medicines, preventing harm to patients

• Medical errors are broader category which includes adverse
  reactions but also other factors (diagnostic errors, equipment
  failure, nosocomial infections ... )
The Role of Pharmacists in
Medication Error Prevention
How Can Pharmacists Reduce ME?
• Clinical pharmacist

• Drug & poison information pharmacist

• Staff pharmacist

• Medication safety pharmacist??
          Pharmacist on Patient-Care Team
     • A full-time unit-based clinical pharmacist substantially
       decreased the rate of serious medication errors in ICU by 66%

     • Studies shows that clinical pharmacy services & increase
       hospital pharmacy staffing are associated significantly with
       reduction in medication errors




Leape LL et al. JAMA.1999,
Kaushal R et al. American Journal of Health-System Pharmacy.2008
      Clinical Pharmacy & ME Reduction
     • Drug histories                     51%

     • Drug information services          18%

     • Adverse drug reaction monitoring   13%

     • Drug protocol management           38%

     • Medical rounds participation       29%




Bond CA et a. Pharmacotherapy.2002
 Always remember

“to Err is Human!”

				
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