Hello Everyone :) I hope this presentation will help us to: Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Identify weaknesses or failures in key elements of the medication-use system. Select effective risk-reduction strategies to prevent medication errors.

1. MEDICATION ERROR
AGA KHAN HOSPITAL (22-JAN-2014)
Presentation By: Beenish Iqbal Arain

2. Objectives
 Definitions
 Causes
 Stages of Medication error
 How to decrease Medication error
Dr:Beenish Iqbal Arain

3. Medication Error Definition
 Medication errors, broadly defined as any error in the
prescribing, dispensing, or administration of a drug,
 Medical errors are often described as human errors in
healthcare
> Such events may be related to:
1) professional practice
2) health care products
3) Procedures and systems
4) product labeling, packaging, and nomenclature
5) dispensing
6) distribution
7) administration
8) education
9) monitoring
Dr:Beenish Iqbal Arain

4. Some reasons errors occur
 verbal orders
 poor communications within healthcare team
 poor handwriting
 improper drug selection
 missing medication
 drug interactions
 availability of floor stock (no second check)
 look alike / sound alike drugs
 hectic work environment
 lack of computer decision support
Dr:Beenish Iqbal Arain

5. Stages of Medication Error
 Phase 1- Ordering/Prescribing
 Phase 2- Dispensing
 Phase 3- Administration
 Phase 4- Monitoring
DR:Beenish Iqbal Arain

6. Ordering/prescribing
 inadequate knowledge about drug indications and contraindications
 not considering individual patient factors such as allergies,
pregnancy, co-morbidities, other medications
 wrong patient, wrong dose, wrong time, wrong drug, wrong route
 inadequate communication (written, verbal)
 documentation - illegible, incomplete, ambiguous
 mathematical error when calculating dosage
 incorrect data entry when using computerized prescribing e.g.
duplication, omission, wrong number
 DR:Beenish iqbal Arain

7. Prescription error example

8. Dispensing
 inexperience
 rushing
 doing two things at once
 interruptions
 fatigue, boredom, being on “automatic pilot”
leading to failure to check and double-check
 lack of checking and double checking habits
 poor teamwork and/or communication between
colleagues
 Too much phone calls
Dr:Beenish Iqbal Arain

9. Dispensing error example

10. Look alike/ sound alike
Sound alike Look alike
 Zantac/Zyrtec
 Rotavir/Ritnovir
 Folic acid/ Folinic acid
 ephederine/ epinephrine
 Doxorubicin/ Daunorubicin
 Celebrex/ cerebryx
DR:Beenish iqbal Arain
 Cyclogest/paracup

11. Look alike examples

12. Administration
 wrong patient
 wrong route
 wrong time
 wrong dose
 wrong drug
 omission, failure to administer
 inadequate documentation

13. Administration error example

14. Monitoring
 lack of monitoring for side-effects
 drug not ceased if not working or course
complete
 drug ceased before course completed
 drug levels not measured, or not followed up
on
 communication failures
Dr:Beenish Iqbal Arain

15. What Can You Do To Decrease Medication
Errors?
 Check and double check, if in doubt check it out, again!
 Follow the 5 R’s: right patient, right drug, right dose, right time, right
route
 Never assume, “pharmacy put the medication in the drawer so this must
be right”, pharmacy makes errors too.
 Never assume, “the resident ordered this large dose so it must be right”,
Residents make errors too.
 Know the correct mg/kg dose of medications you are administering.
 Know why you are giving the medication, the expected action, and any
potential side effects.
DR:Beenish Iqbal Arain