Medication errors are a major concern in the healthcare fraternity. Although unintended, medication errors continue to happen everyday resulting in patient harm.

1. PUNE ADVENTIST HOSPITAL
Training on:

2. Medication error
A preventable event that may cause or lead to
inappropriate medication use or patient harm
while the medication is in the control of the
healthcare professional, patient, or consumer

3. Near miss
• An event or situation that happens by chance
but doesn’t produce patient injury. A near
miss is considered an error.

4. Factors contributing to medication
errors
• Human related
• System related
• Medication related

5. Human related factors
HCP
• Over worked
• Under trained
• Competence
• Distracted
• Illness
• Stress
Patients
• In a hurry
• Health literacy level
• Do not understand
medication use
• Trust providers to not
make mistakes

6. System – related factors
• Lack of communication
• Poor workflow
• Disorganized workspace
• Inadequate tools to complete work
• Lack of supervision

7. Medication – related factors
• Look alike/ sound alike medications
• Multiple dosage forms and strengths

8. 6 Rights
• Right drug
• Right route
• Right time
• Right dose
• Right patient
• Right dosage form

9. Types of medication errors
• Prescribing error
• Dispensing error
• Documentation error
• Administration error
• Transcription error
• Indent error

10. Prescribing error
• Occurs as a result of a faulty prescribing
decision or prescription writing process. It
includes:
i. incorrect prescription
ii. Illegible handwriting
iii. Drug allergy not identified
iv. Irrational combinations
v. Out of list abbreviations

12. When prescribing...
• Always use Sign. Name, Date Time (SNDT)
format, all capitals
• Always use decimal points for dosage, and 0
before the decimal point rather than after the
digit

13. Dispensing error
• Currently, the accuracy stands at 98.3% in
dispensing medication
• 1.7% inaccuracy and error

14. Prevalent dispensing errors
• Dispensing incorrect medication, dosage
strength or dosage form
• Dosage miscalculation
• Failure to identify drug interactions or
contraindications

15. LASA medication

16. Errors of omission
• Failure to counsel the patient
• Failure to screen for drug interactions and
contraindications

17. Errors of commission
• Miscalculation of a dose
• Dispensing the incorrect medication dosage
strength or dosage form

18. Dispending errors: common causes
• Work environment
i. Workload
ii. Distraction
iii. Work area
• Use of outdated or incorrect references
• LASA drugs

19. Prescribing, Dispensing error e.g.
1
• Prescription for primidone
• Interpreted as prednisone
2
• Consumption of prednisone for 4 months
• Acquires steroid induced diabetes
3
• Diabetes goes unrecognized
• Patient dies of diabetic ketoacidosis

20. Administration error
• A discrepancy between drug therapy received by the
patient and therapy intended by the prescriber.
• Accounts for 26% - 32% of total medication errors
• Involves discrepancy in one of the 6 - Rights

21. Causes of Administration Errors
• Failure to check patient’s identity
• Wrong calculation to determine correct dose
• Poor lighting
• Noise interruption
• Lack of knowledge of the preparation or
administration
• Complex design of equipment

22. Administration error e.g.
• The nurse is catching up on all patients
morning medication
• Patient’s condition deteriorates and he is
intubated
• The nurse decides to crush all medicines and
administer via NG tube
• Crushes an extended – release Ca channel
blocker
• Patient’s heart rate slows to asystole, patient
dies

23. Transcription error
• Factors contributing to transcription error are
i. Illegible prescription
ii. Use of abbreviations
iii. Lack of familiarity with drug names

24. Indent Error