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									Chapter 6
 Medication Safety
             Learning Objectives
• Understand the extent and effect of medical errors on
  patient health and safety
• Describe how and to what degree medication errors
  contribute to medical errors
• *List examples of medication errors commonly seen
  in practice settings
• Apply a systematic evaluation of opportunities for
  medication error to a pharmacy practice model
• Identify the common medication error–reporting
  systems available
                   Medical Errors
• A medical error is any circumstance, action, inaction,
  or decision related to healthcare that contributes to an
  unintended health result
• Most of what is known about medical errors comes
  from information collected in the hospital setting
   – hospital data make up only a part of a much larger picture
   – most healthcare is administered in the outpatient, office-
     based, or clinic setting
• Medical errors are difficult to define
   – possible causative circumstances are infinite
                   Medical Errors
• Medical-related lawsuits show the scope of medical
  errors in the United States
• One large government studied only medical errors
  during hospitalization
   – 44,000 to 98,000 people in the U.S. die each year as a
     result of medical errors (greater than the risk of death from
     accident, diabetes, homicide, or human HIV and AIDS)
   – multiple sources for potential medical errors exist

                What are some examples of medical errors?

Edited by Dr. Ryan Lambert-Bellacov

What are some examples of medical errors?

Answer: Lab tests drawn at the wrong time
(inaccurate results), major surgical errors ending
in injury or death
               Medication Errors

• A medication error is a medical error in which the
  source of error or harm includes a medication
• Like medical errors
   – medication errors have no specific definition because
     the possible causes can be endless
   – information on the effect of medication errors comes
     mostly from studies done in the hospital setting
• Medication-related deaths are estimated at about
  7,000 each year
               Medication Errors

• Fewer studies of medication errors in community
  practice exist
   – an estimated 1.7% of all prescriptions dispensed in a
     community practice setting contain a medication error
     (4 of every 250 prescriptions)

• Not all medication errors result in harm to a patient
   – 65% of the medication errors detected had a meaningful
     effect on the patient’s health
                Medication Errors
• Measuring results of medication errors
   – lost lives
   – disabled patients
   – time lost from work or school

• cost to the healthcare system
   – billions of dollars             – physician visits
   – additional hospitalizations     – emergency room visits
   – admissions to long-term care    – continuation of disease
Healthcare Professional’s Responsibility
• Working in healthcare means making a commitment
  to “first do no harm”
• The profession of pharmacy exists to safeguard the
  health of the public
• Healthcare must focus on treating the patient
   – to the best possible outcome
   – by the safest possible means
• No “acceptable” level of medication error exists
   – effect of a potential medication error on the patient cannot
     be predicted
   – each step in fulfilling medication orders should be reviewed
     with a 100% error-free goal
  Healthcare Professional’s Responsibility

         The only acceptable level of medication errors
         is zero.

Edited by Dr. Ryan Lambert-Bellacov
Healthcare Professional’s Responsibility
• MA’s can identify potential patient sources of
  medication error
   – careful listening and observation during a patient or medical
     staff interaction
   – notifying the pharmacist

• MA’s make a significant contribution to patient safety
   – constant surveillance for potential sources of medication
 Tips for Reducing Medication Errors
• Always keep the prescription and the label together
• Know common look-alike and sound-alike drugs
• Keep dangerous or high-alert medications in a
  separate storage area
• Always question bad handwriting
• Prescriptions/orders should be correctly spelled with
  drug name, strength, appropriate dosing, quantity or
  duration of therapy, dose form, and route
• Use the metric system
    Tips for Reducing Medication Errors
•   Question uncommon abbreviations
•   Be aware of insulin mistakes
•   Keep the work area clean and uncluttered
•   Verify information
•   Labels should always be compared with the original
    prescription by at least two people
              Healthcare Professional’s

          If information is missing from a medication
          order, never assume. Obtain the missing
          information from the prescriber.

Edited by Dr. Ryan Lambert-Bellacov
    Tips for Reducing Medication Errors:

    •   Use the triple-check system
    •   Regularly review work habits
    •   Verify information with the patient or caregiver
    •   Observe and listen
    •   Keep your work area free of clutter

Edited by Dr. Ryan Lambert-Bellacov
               Patient Response
• Most patients have the intended therapeutic
  response expected from the medication

• Unique physical and social circumstances make it
  impossible to predict which
   – medication errors may result in no substantial harm
   – may result in death
  Physiological Causes of Medication
• Each patient has a unique response to medication
   – genetically unique
   – speed at which medications are removed from
     body varies

• Even a problem caught and corrected before harm
  occurs is still considered a medication error
      Social Causes of Medication Errors
    • Outpatients can contribute to medication errors
      through incorrect administration

    • Social causes of error include:
        – failure to follow medication therapy instructions because
          of cost
        – noncompliance
        – failure to receive therapy
        – misunderstanding instructions (language barriers)

Edited by Dr. Ryan Lambert-Bellacov
  Social Causes of Medication Errors

• Patients can contribute to medication errors by
   – forgetting to take a dose or doses
   – taking too many doses
   – dosing at the wrong time
   – not getting a prescription filled or refilled in a timely
   – not following directions on dose administration
   – terminating the drug regimen too soon
 Social Causes of Medication Errors

• Social causes may result in an adverse drug
  reaction, or a toxic dose

• Over 50% of patients on necessary long-term
  medication are no longer taking their medication
  after 1 year

• All of these social circumstances would be
  considered medication errors
         Categories of Medication Errors

     • Possible causes of a medication error are

     • Categorizing errors into types aids in identification
       and prevention of possible causes

     • Categories focus on grouping errors under a set of
       common definitions

Edited by Dr. Ryan Lambert-Bellacov
    Categories of Medication Errors
• omission error: a prescribed dose is not given
• wrong dose error: a dose is either above or below the
  correct dose by more than 5%
• extra dose error: a patient receives more doses than
  were prescribed by the physician
• wrong dose form error: dose form or formulation that
  is not the accepted interpretation of the physician order
• wrong time error: drug is given 30 minutes or more
  before or after it was prescribed
   Categories of Medication Errors
• Errors can be classified by what causes the failure
  of the desired result

• Errors can be categorized within three basic
  definitions of failure:
   – human failure
   – technical failure
   – organizational failure
    Categories of Medication Errors
• Human failure is a failure that occurs at an
  individual level
   – pulling a medication bottle from the shelf based on
     memory, without cross-referencing the bottle label with
     the medication order/prescription
   – errors made by the patient such as non-compliance to
     prescribed drug therapy
• Technical failure is a failure resulting from
  location or equipment
   – incorrect reconstitution of a medication because of a
     malfunction of a sterile-water dispenser
   – failure to properly operate automated equipment
  Root Cause Analysis of Medication
• Root cause analysis is a logical and systematic
  process used to help identify what, how, and why
  something happened to prevent reoccurrence

• With basic principles of root cause analysis, any
  person can
   – examine his or her own work flow to determine the
     opportunities for potential error
   – determine what type of failure the potential error may be
   – create a list of specific potential causes
  Root Cause Analysis of Medication

• Identifying specific potential causes allows a person
  to take specific actions to prevent the potential error
• Actions taken improve the quality of work being done
• Common causes of medication error by handlers and
  preparers include:
   – assumption error
   – selection error
   – capture error
  Root Cause Analysis of Medication
• assumption error: an essential piece of information
  cannot be verified and is guessed or presumed
   – misreading an abbreviation on a prescription
• selection error: two or more options exist, and the
  wrong option is chosen
   – using a look-alike or sound-alike drug instead of prescribed
• capture error: focus on a task is diverted elsewhere
  and an error goes undetected
   – something captures the person’s attention, preventing the
     person from detecting the error or causing an error to be
      Root Cause Analysis of Medication

            Maintaining focused attention when filling
            prescriptions is important to avoid errors.

Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process in Community
     and Hospital Pharmacy Practice

• Review for potential causes of medication error
  begins with outlining work tasks in a step-by-step

• Each step in this process can be a
   – source of medication error
   – place where pharmacy personnel can correct a
     medication error
    Prescription-Filling Process in Community
         and Hospital Pharmacy Practice

           Each person who participates in the filling
           process has the opportunity to catch and correct
           a medication error.

Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process

          Outdated prescriptions should not be filled.

Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process

           A prescriber’s signature is required for a
           prescription to be considered valid.

Edited by Dr. Ryan Lambert-Bellacov
              Prescription-Filling Process
                         Step 1
    • Prescribing errors include:
       –   poor handwriting
       –   using nonstandard abbreviations
       –   confusing look-alike and sound-alike drug names
       –   wrong drug
       –   using “as directed” instructions

Edited by Dr. Ryan Lambert-Bellacov
             Prescription-Filling Process
                        Step 1

Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process

           A leading zero should precede values less than
           one, but a zero should not follow a decimal if
           the value is a whole number. A tenfold error
           occurs if the decimal point is not detected.

Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process
                       Step 1
  • Opportunities for medication errors increase with the
    number of medications a patient takes
      – common with many older patients

  • Profile review for every prescription should include:
      – check for existing allergies and multiple drug therapy
      – check for drug interactions or duplication of therapy

Edited by Dr. Ryan Lambert-Bellacov
            Prescription-Filling Process

         Check the patient profile for existing allergies
         or possible drug interactions.

Edited by Dr. Ryan Lambert-Bellacov
       Prescription-Filling Process
               :Retrieve Medication

• Products can contribute to errors with
   – look-alike labels
   – similarities in brand or generic names
   – similar pill shapes or colors
• Use NDC numbers, drug names, and other
  information to verify selection of the correct product
   – use both the original prescription and the generated label
     when selecting a manufacturer’s drug product from the
     storage shelf
   – use NDC numbers as a cross-check
       Prescription-Filling Process
    Step 5: Fill or Compound Prescription

• Calculation and substitution errors are sources of
  medication errors
   – write out the calculation and have a second person check
     the answer

• Take care when reading labels and preparing
  compounded products
       Medication Error Prevention

• Preventing medication errors means
   – carefully examining potential points of failure
   – using available resources to verify information given or
     decisions made

• Drug identification is the most common error in
  dispensing and administration
           Medication Error Prevention

       Incorrect drug identification is the most common
       error in dispensing or administration.

Edited by Dr. Ryan Lambert-Bellacov
        Medication Error Prevention
• Many medication errors occur during prescribing
  and administration
• Prescribers are responsible for ensuring the “five
  Rs” or five rights
   – the right drug
   – for the right patient
   – at the right strength
   – given by the right route
   – administered at the right time
    Innovations to Promote Safety

• The physical pharmacy work setting can have a
  major contribution to the overall safety of any
  work environment
• Automate and bar code all fill procedures
• Maintain a clean, organized, orderly work area
• Provide adequate storage areas
• Encourage prescribers to use common
  terminology and only safe abbreviations
• Provide adequate computer applications and
     Innovations to Promote Safety
• Innovations can minimize possibility of errors
• In community pharmacy, redesigned packaging helps
  patients take medication safely
  – Target ClearRx packaging helps patients manage their
      • colored rings help patients identify medications intended for
        each family member
      • clear, easy-to-read label for patient administration
        instructions and cautions
      • includes a pullout patient information card or printout

  Learn more about the Target label design
      Innovations to Promote Safety
• In hospital pharmacy, integrated computerized filling
  systems allow institutions to
   – improve efficiency
   – redirect resources
 Medication Error and Adverse Drug
   Reaction Reporting Systems
• The first step in prevention of medication errors is
  collection of information
• Fear of punishment is a concern with errors
   – people may decide not to report an error at all
   – allows the same error to occur again and again
• Anonymous (no-fault) reporting systems have been
   – focus on fixing the problem, not fixing the blame
         State Boards of Pharmacy
• More than 20 states have mandatory error-
  reporting systems
   – most state officials admit medical errors are still under-
     reported mostly because of fear of punishment

• Some states have worked to reduce the fear of
   – allow pharmacists to document errors and error-prone
     systems without worry of punishment
   – most boards of pharmacy will not punish pharmacists
     for errors
         State Boards of Pharmacy
• Pharmacy technicians are an integral part of the
  error identification, documentation, and prevention

• The final and most important piece of medication
  error reporting is informing the patient that a
  medication error has taken place
   – commonly the task of the pharmacist
                    State Boards
• The circumstances leading to the error should be
  explained completely and honestly
• Patients should understand
   – the nature of the error
   – what if any effects the error will have
   – how they can become actively involved in preventing
     errors in the future
• People are more likely to forgive an honest error
Joint Commission on Accreditation for
       Healthcare Organizations
• Organizations can create a centralized point through
  which all members may channel error information
• The Sentinel Event Policy was created by the Joint
  Commission on Accreditation for Healthcare
  Organizations (JCAHO) in 1996
• A sentinel event is an unexpected occurrence
  involving death or serious physical or psychologic
Joint Commission on Accreditation for
       Healthcare Organizations
• When a sentinel event is reported, the organization is
  expected to
   – analyze the cause of the error (perform a root cause
   – take action to correct the cause
   – monitor the changes made
   – determine whether the cause of the error is eliminated
• Accreditation of hospitals depends on demonstrating
  an effective active error–reporting system
  Learn more about the Joint Commission International Center for Patient

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