Medication Errors MEDICATION ERRORS PHR222 Hospital Pharmacy Outline • Definition •

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Medication Errors MEDICATION ERRORS PHR222 Hospital Pharmacy Outline • Definition • Powered By Docstoc

  Hospital Pharmacy

•   Definition
•   Medication error severity levels
•   Flow chart of medication errors
•   Types of medications errors
•   Causes of medications errors
•   Risk factors of medications errors
•   Medications errors prevention
            Medications errors

• An error in which a patient is given an
  inappropiate drug, or a drug is given at the
  wrong dose, frequency, or via incorrect route
  of administration

(Durgin JM et al, AJHP 1971)
• The main goal of drug therapy is to achieve a defined
  therapeutic outcomes that improves a pt’s QOL
• However, there are inherent risks (known & uknown)
  assoc. with therapeutic use of drug administration.
• Problems & sources of ME are multidiciplinary &
• May be comitted by both experience& inexperience
• Many ME are probably undetected
          ME severity levels
LEVEL 1   Error did not result pt harm
LEVEL 2   Error result ↑pt monitoring but no VS
          change & no pt harm
LEVEL 3   Error, ↑monitoring, VS change , no need
          for lab monitoring
LEVEL 4   Error, tx with other drug prolonged
          hospital stay
LEVEL 5   Error permanent pt harm
LEVEL 6   Error pt death
                 Flow chart of ME Points
                               Prescriber writes Rx

                        Pharmacy receives, screen & interpret the Rx

                        Drugs put into medication drawer/ bin of
                        individual pt by pharmacy assistant

      Trolley              Counterchecking med filled bf delivery
      return bck to
                            Trolley with med bins send to ward
drug to pt                 Pt in ward
Point for prescribing error

Point for dispensing error

Point for error by nurses

Point for error by patient
                 Type of ME

1. Prescribing errors
  – Incorrect drug , rouelection ( based on indications,
    C/I, known allergies, existing therapy) dose,
    dosage form, quantity, route, concentration, rate
    of administration or instruction for use.
2. Omission errors
  – Failure to administer an ordered dose to a pt
    before the next scheduled dose
3.Wrong time error
  – Administration of medication outside a predefined
    tiem interval from its scheduled time
• Improper dose error
  – Administration to pt of a dose that is > or <
    amount ordered by prescriber
• Wrong dosage form error
  – Administration to pt of a drug product in a
    different dosage form than ordered by prescriber
• Wrong drug-preparation error
  – Drug product incorrectly formulated or
    manipulated bf administration
  – ( eg: incorrect dilution or reconstitution mixing
    incompatible & inadequate product packaging
8. Wrong administration –technique error
     - Inappropriate procedure or improper
     technique in administration of a drug
     ( eg. Wrong route & site of administration,
  wrong route)
9. Deteriorated drug error
  – Administration of a drug that expired or for
    which the physical or chemical dosage form
    integrity has been compromised.
10. Monitoring error
  – Failure to use appropiate clinical or laboratory
    data for adequate assessment of pt response to
    prescribed therapy
11.Compliance error
  – Inappropiate pt behavior regarding adherence to a
    prescribed regimen
  Causes of
Medication Error
1. Inexperienced personnel
2. Failure to adhere to work
3. Look-alike medication/packaging
4. Peak hour
5. Illegible prescription
6. Patient info/record
7. Stock arrangement/storage problem
8. Sound-alike medication
9. Wrong labeling/instruction on
   dispensing envelope or bottle/container

Description: types of medication errors and its definition