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Medication safety 2011
1.
2. • Definitions
• The relationship between medication error, ADE & ADR
• Classifications, types & Reasons of medication error
• How to prevent medication error (Identifying, Focusing )
• How to approach error (Person Vs. System)
• Methods used to minimize or reduce medication errors
• Medication error reporting
3. • The goal of drug therapy is the achievement of defined
therapeutic outcomes that improve a patient’s quality of life
while minimizing patient risk
• With every therapy there must be a risk, it could be known or
unknown
• These risks are defined as drug misadventures, which includes
both adverse drug reactions (ADRs) & medication errors
4. • Medication error
Any preventable event that has the potential to lead to
inappropriate medication use or patient harm during
prescribing, transcribing, dispensing, administering,
adherence, or monitoring a drug
• Near Misses Or A Potential Adverse Drug Event :
Medication errors that are stopped before harm are sometimes called
5. • Adverse drug event (ADE)
Any injury caused by a medicine or lack of intended
medication ( e.g. Adverse drug reactions & overdoses, Dose
reductions & discontinuations of drug therapy)
• Adverse drug reaction (ADR)
Any unexpected, unintended, undesired, or excessive
response to a drug, with or without an “injury”
7. • Medications harm at least 1.5 million people per year
• 44,000 to 98,000 hospitalized Americans die each year from medical error
• Medication Errors cause more death each year than breast cancer, motor
vehicle accidents & AIDS
• The financial burden from these medical errors is estimated to be in a range
of $30 billion to $130 billion annually
• Up to 28% of these events are thought to be preventable
Institute of Medicine. Preventing medication errors: quality chasm series, 2006
What Is The Evidence That Patient Safety Is A Problem?
8. Phillips DP. Annu Rev Public Health. 2002;23:135-50.
Deaths from
Medication Errors
1983 1998
9.
10. NCC MERP index ( National Coordinating
Council for Medication Error Reporting and
Prevention index) for categorizing medication
errors
Medication Use System
11.
12. Selection &
Procuring
Establish
formulary
Monitoring
Assess patient
response to
drug; report
reactions &
errors
Administering
Review
dispensed drug
order; assess
patient &
administer
Preparing &
Dispensing
Purchase &
store drug;
review &
confirm order;
distribute to
patient location
Prescribing
Assess patient;
determine need
for drug
therapy; select
& order drug
High-Level Portrayal of a Medication Use System
Clinician &
administrators
Physician/
prescriber
Pharmacist Nurse/other
health
professionals
All
practitioners,
plus patient
&/or family
Joint Commission. 1998
14. It is an incorrect drug selection for a patient including (the dose,
strength, route, quantity, indication, or prescribing
contraindicated drug ) also failure to comply with legal
requirements for prescription writing
Contributing factors:
• Illegible handwriting
• Inaccurate medication history taking
• Confusion with the drug name
• Use of abbreviations
• Use of verbal order
Williams DJ. 2007,
Lesar et al. JAMA. 1997
16. 6 unties of regular insulin now
Name That Drug…
Filled Rx: 60 units
17. • It is an error that occurs at any stage during the dispensing
process from the receipt of a prescription in the pharmacy
through to the supply of a dispensed product to the patient
• Studies have estimated that dispensing errors occur at a rate of
1-24%
• These errors include the selection of the wrong
strength/product. This occurs primarily when 2 drugs have a
similar appearance or similar name (look-a-like/sound-a-like
errors)
21. • Defined as a discrepancy between the drug therapy received by
the patient & the drug therapy intended by the prescriber
• HIGHEST RISK AREAS IN NURSING PRACTICE
• It involve errors of omission where administration is omitted
due to a variety of factors e.g. wrong patient, lack of stock
• Also wrong administration technique, administration of
expired drugs & wrong preparation administered
22. Contributing factors:
• Failure to check the patient’s identity prior to
administration
• Storage of similar preparations in similar areas
• Errors
Williams DJ. 2007
• More than one tablet for a single dose
• Calculation is required to determine the
correct dose
23. A patient had an epidural line for pain management & a
peripheral IV line containing insulin
The nurse caring for the patient was busy & asked a second
nurse to retrieve the next scheduled epidural infusion bag
The second nurse delivered a new bag of insulin to the
patient’s bedside
Without checking the label, the primary nurse hung the insulin
infusion to the epidural line
24.
25. Step One See the problem
Step Two Identify the risk
Step Three Manage It
26. How Can We Identify The Risk?
• High alert medication
• Error prone notations
• Look-a-like & sound-a-like medications
27. What are high alert medications?
United States Pharmacopeia.2007
Agent % of Drug Errors Associated with Acute Hospital Care
Insulin 4% of all medication errors in 2005
Morphine 2.3%
Potassium Chloride 2.2%
Albuterol 1.8%
Heparin 1.7%
Vancomycin 1.6%
Cefazolin 1.6%
Acetaminophen 1.6%
Warfarin 1.4%
Furosemide 1.4%
28. Strategies To Reduce Risk From High-Alert
Medications
• Limit the access to these medications
• Standardizing the ordering/preparation &
administration
• Independent double check at dispensing &
administrating phase
29. Error-Prone Notations
• Ambiguous medical notations are one of the
most common & preventable causes of
medication errors
• Misinterpretation may lead to mistakes that result
in patient harm
• Delay start of therapy due to time spent for
clarification
30. • ISMP & FDA recommend that ISMP’s list of
error-prone abbreviations be considered
whenever medical information is communicated
ISMP= Institute for Safe Medication Practices,
FDA= Food and Drug Administration
Complete list is located at:
www.ismp.org/Tools/errorproneabbreviations.pdf
31. * Comprises “Do Not Use” list required for JCAHO accreditation
Notation Reason Instead Use
U Mistaken for 0, 4, cc Unit
IU Mistaken for IV or 10 Unit
QD Mistaken for QID Daily
QOD Mistaken for QID, QD “every other day”
cc Mistaken for U “mL”
μ Mistaken for mg “mcg”
@ Mistaken for 2 “at”
D/C, dc, d/c Misinterpreted as when “discontinued” followed by
list of medications
“discharge” or
“discontinued”
Refer back to our Policies folder for full list
32. Intended dose of 4 units
Administered 44 units
Should be written as “4 units”
36. Person-Centered Approach
• It has been traditional used in analysis of medication
errors
• It looks at medication errors as occurring due to
human frailty, including
Forgetfulness
Poor motivation
Carelessness, not paying
attention
Negligence
37. System-Centered Approach
– Errors expected to occur
– Errors are viewed as the end result & not the cause
– There is potential for error & recurring errors in
every system, & even the best systems fail
38. System-Centered Approach
• Solutions are based on the belief that conditions can
be changed, rather than focusing on changing humans
• Barriers & safeguards should be implemented to help
prevent errors
• It is essential to focus on how & why the system
failed & not on which individual failed
41. Forcing functions & constraints
Automation & computerization
Standardization & protocol
Checklist & double check system
Rules & policies
Education/ Information
Be more careful
Most
effective
Least
effective
42. Forcing functions & constraints
• Use pharmacy system that will not fill any order unless allergy
information, patient weight & height are entered
• Use computer order entry with dosage checks
• Remove dangerous IV drugs (e.g. conc. potassium, hypertonic
sodium chloride) from ward stock
• Limit choices of available drugs in pharmacy
• Limit dosage strengths & concentration for each drug
• Mix IVs in the pharmacy
43. Automation & computerization (Reduce reliance on memory)
• Use drug-drug interaction checking system
• Use computerized order entry
• Use computerized patient information
• Use bar-coding on drugs, containers, medication records, patient
wristbands
• Automated dispensing on patient care unit
44. Standardization & protocol
• No error –prone abbreviations
• Use generic names rather then brand name
• Use standard equipment—one kind of pump or syringe
• Use protocol for complex medication administration e.g.
heparin, chemotherapy
45. • Stay current & knowledgeable concerning changes in
medication & treatment
• Utilize pharmacist consultation if available
• Ensure that drug orders are complete, clear, unambiguous &
legible
Including patient weight, dosage (mg/kg/dose or/day), frequency & route
of administration
Avoid use of terminal zero e.g. use 5 rather 5.0
Use a zero to the left of a zero ( use 0.2 rather .2 )
• Discuss medication changes with nursing & other staff &
families
46. • Independent double check orders both on calculation &
preparation
• Clarify confusing orders
• Checking for current patient drug allergy
• Dispense medication using unit-dose, ready to administration
form whenever possible
• Patient name, generic drug name, patient specific dose on all
labels
47. • Double check medication calculations
• Verify drug order & confirm patient identity &
weight before administration
• Have access to drug information on all medications
• Familiar with the operation of medication
administration device
