The document discusses medication errors, including their definition, causes, and stages. Medication errors can occur at several points including ordering, dispensing, administration, and monitoring. They may be caused by issues like poor communication, look-alike or sound-alike drug names, distractions, and fatigue. To reduce errors, the document recommends always double checking medications against the 5 rights and not assuming others have already caught any mistakes.

1. MEDICATION ERROR
AGA KHAN HOSPITAL
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