Prince Sultan Cardiac Center-Hofuf
    Pharmacy Care Department
 is any preventable event that
      may cause or lead to
inappropriate medication use or
   harm to a patient while the
medication is in the control of the
health care professional, patient,
          or consumer..
PRESCRIBING       42%       48%         28%

TRANSCRIBING      12%       33%         11%

DISPENSING        11%       33%         10%

ADMINISTRATION    35%       2%          51%
 Incorrect drug selection (based on indications,
 contraindications, known allergies, existing
 medication therapy, and other factors), Dose, Dosage
 form, Quantity, Route, Concentration, Rate of
 administration, or instructions for use, illegible
 prescriptions or medication orders that lead to errors
 that reach the patient.
 Order is not transcribed at all
 Order is transcribed incorrectly
 Allergy is not documented on the
 medication administration record
 Allergy is not documented on the
 order sheet
• Wrong dispensed drug, dose, or dosage form.

• Incorrect directions given to the patient (written
  or verbal).

• Failure to counsel an unknowing patient about
  proper use of drug.
• Dispensing an expired or degraded drug.

• Failure to review the drug regimen for
• Failure to correct problems with the drug
 Omission Error
  The failure to administer an order dose to a patient
   before the next scheduled dose, if any.
 Wrong Time Error
  Administration of medication outside a pre-
   defined time interval from its scheduled
   administration time.
 Wrong Medication – Preparation Error
  Medication product incorrectly formulated or
   manipulated before administration.
 Improper Dose Error
  Administration to the patient of a dose that is
   greater than or less than the amount ordered by
   the prescriber.
  Administration of duplicate doses to the patient.
  Example: one or more dosage units in addition to
   those that were ordered.
 Wrong Administration Technique Error
  Inappropriate procedure or improper technique in
   the administration of a medication.
  Example: wrong route/site or rate of
 Monitoring Error
  Failure to review a prescribed regimen for
   appropriateness and detection of problems.
  Failure to use appropriate clinical or laboratory data
   for adequate assessment of patient response to
   prescribed therapy.

Compliance Error
  Inappropriate patient behavior regarding
  adherence to a prescribed medication regimen.
In 2000, the institute of Medicine (IOM) – United
  States, reported 6,000 deaths caused by occupational
  injuries. However, 7,000 deaths yearly were caused by
  medication errors.

 5 medication errors occur in 100 medication
 Adverse Drug Events occur at an estimated rate of 6.5
  per 100- hospital admissions; 28% are considered
 56% of medication errors are related to prescriptions.
 Nurses were blamed for medication errors when the
  source was traced to the prescriber of the medication.
 IV medications and infusion pumps are also
  increasingly viewed as safety concerns.
 46% of all medication errors occur during transition of
  care such as patient transferred from one unit to
  another, nursing handover, patient admission and
 40%    -    wrong dose
 19%   -     wrong medication
 9%     -    wrong route

Of these errors:
 44% -        were due to knowledge deficit
 15% -        was due to communication errors
 Accept that errors will occur.
 Redesign the system
 Focus on the system, not on the people
 Everyone is involved in safety
 Make the medication error visible
 Minimize the consequence of medication error
 Report, analyze and share medication error
 Promote a just culture – non punitive
  environment – in reporting medication errors
 Adopt a system-oriented approach to
  medication error reduction
 Use of technology effectively such
  Implement Computerized Physician Order Entry
  Use of Automated Dispensing Cabinets
  Use of Pharmacy Dispensing Robotics
  Use of Bar-coding in medication and patient
  Use of smart Infusion Pumps.

 Use of defaults:
   Pre-established parameters take effect
   Examples: morphine concentration default
    for PCA pump.
 Limit medication manufacturers
 Implement standard processes for medication
  doses and dose timing.
 Standardize prescribing rules and avoid
  prohibited abbreviations.
 Implement a unit dose system
 Have the Pharmacy supply High-Alert
  intravenous medications and Do Not store
  concentrated electrolytes solutions on patient
  care units.
 Use special procedures and written protocols
  for the use of High-Alert Medications
 Ensure the availability of Pharmacist during
  patient care rounds.
 Make relevant patient information available at
  the point of care
 Provide electronic medication information
 Differentiation – TALL man lettering, separate
  storage areas, color differentiation, and change
 Write a complete, clear,                     Avoid Potentially
  un-ambigous order.                       Dangerous abbreviations
                                            and dose expressions

 Use metric system and                       Never abbreviate drug
USP standard for dosage                     names unless common
   unit abbreviation                        and on an approved list

                          Think Patient.
                    Ensure Patient Safety While
                       Giving Verbal Orders
     Can you READ this ?

                   Did you know ?

Poor handwriting is a major cause of medication errors.

35% of outpatient and 14 % of inpatient orders, can not
be read.
  Remove High
                                          Properly label
                                        every medication

Use Tallman letters,                       Double check each
   Proper spacing,                            prescription or
insert purpose field,                     medication protocols
  Pre-printed drug                       received, verify with the
       orders                              prescriber if there is

Double-check            Ensure proper
before sending            storage of             Deliver Medications
 medication              dispensed                in timely fashion
protocol to the           medicine
Don’t Trust Your       Verbal medication orders can
   Hearing             be misheard, misunderstood,
                            or mistranscribed.

 Always remember “
 when confuse, it is
      unsafe”             It is always unsafe when
                          confused. Never assume
                            you know everything.
                         Crushing certain oral
                       medications may destroy
Ask before you crush   the intended effect of the
                        drug and in some cases
                       cause an adverse reaction.

  Double Check
     before            Once administered, there is
  Administration            no turning back

             AUTOMATION &


              CHECK SYSTEMS

             RULES & POLICIES

 Medication errors should be identified and
  documented and their causes studied in order to
  develop systems that minimize recurrence.
 The error classification should be based on the
  original order, standard medication dispensing and
  administration procedures, dosage forms available,
  acceptable deviation ranges, potential for adverse
  consequences, patient harm and other factors.
 Any necessary corrective and supportive therapy
  should be provided to the patient.
 The error should be documented and reported
  immediately after discovery, in accordance with
  written Policies & Procedures.
 For clinically significant errors, fact gathering and
  investigation should be initiated immediately.
 Report of clinically significant errors and the
  associated corrective activities should be reviewed by
  the supervisor and department head of the area(s)
  involved, the appropriate organizational administrator,
  and the organizational patient safety committee.
 Information gained from medication error reports should
  serve as an effective management and educational tool in
  staff development and, if necessary, modification of job
  functions or health care provider disciplinary action.
 Medication errors should be reported to a national
  monitoring program so that the shared experiences of
  Pharmacists, Nurses, Physicians, and Patients can
  contribute to improved patient safety and to the
  development of valuable educational services for the
  prevention of future errors.
Sample Prescriptions
  & Protocols with
Category/Error              Error Outcome
  Near Miss                    NO HARM
      A          Circumstances or events that have the
                 capacity to cause error
    Error                      NO HARM
      B          An error occurred, but the error did not
                 reach the patient
      C          An error occurred that reached the
                 patient but did not cause patient harm
      D          An error occurred that reached the
                 patient, and required monitoring to
                 confirm that it resulted in no harm to
                 that patient, and/or required
                 intervention to preclude harm.
Error                    HARM
 E      An error occurred that may have
        contributed to or resulted in temporary
        harm to the patient and required
 F      An error occurred that may have
        contributed to or resulted in harm to
        the patient and required initial or
        .prolonged hospitalization
 G      An error occurred that may have
        contributed to or resulted in permanent
 H      An error occurred that required
        intervention necessary to sustain life.
Error                   DEATH
        An error occurred that may have
        contributed to or resulted in the
        patient’s death.
         FROM                          TO
Who did it?               How did it happen?

Punishment                Thank You!

Errors are rare           Errors will happen

Only Nurses involved      Everyone is involved in
                          problem solving
Add more layers           Simplify/ Standardize

Calculating error rates   Learn from error reporting

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