medical error

1. MEDICAL ERRORS
Ms. Chanda Jabeen
Lecturer
RN, RM, BSN
M.Phil. Epidemiology & Public Health
PhD (Scholar) Epidemiology & Public Health
1

2. OBJECTIVES
1. Define the medical errors and medication
error.
2. Explain the burden of the medication errors.
3. Explore the causes of medication errors.
4. Discuss the Swiss Cheese Model.
5. Discuss types of medication errors.
6. Explain Steps for prevention medication
errors.
2

3. MEDICAL ERROR
Failure of a planned action to be completed as
intended or the use of a wrong plan to achieve an
aim.
For example: an adverse drug event, improper
transfusion, surgical injuries and wrong site injuries,
suicide, restraint-related injury or death, falls, burns,
pressure ulcers and mistaken patient identity.
At least 44,000- 98,000 people die in hospitals each
year from preventable medical errors.

4. “Any preventable event that may cause or lead
to inappropriate medication use or patient
harm while the medication is in control of the
health care professional, patient, or consumer”
• May occur at any time, from the prescription
to consumption of the medicines by the
patient
.
MEDICATION ERROR
4

5. BURDEN OF THE
MEDICATION ERRORS.
5

6. Study conducted in Indonesia showed following
results (Ernawati,Lee & Hughes, 2014).
6

7.  80,000 people annually died in the United States
alone due to medication errors (Stoppler,2012).
 Medical errors are the eighth leading cause of
death in this Pakistan and about 7,000 people
per year are estimated to die from medication
errors alone(The Nation,2011).
 In Pakistan the main error rate is 5.5% and
pharmacists contributed a higher error rate of
2.6% followed by nurses (1.1%) and physicians
(1%) (Khowaja et al.,2008).
7

8. According to a survey by European Commission
(EC), the highest number of medical errors related
incidents in hospitals are found in
 Latvia (32%),
 Denmark (29%) and Poland (28%)
 Austria tops the ranking having both the fewest
medical errors in hospitals (11%) and in medical
prescriptions (7%)
(European Commission,2006).
8

9. • Errors of Omission: errors related to
prescription, drug dispensing by pharmacist,
drug administration by medical personnel like
nurses & patient themselves
• Errors of Commission: most common
form of errors encountered in clinical
practice, this include
1.)Wrong phenomenon
2.) Drug interaction
related
CAUSES OFERRORS
9

10. 3.) Communication failure
4.) Failure to follow appropriate policies
related to drug use
5.) Failure to follow drug-specific
instructions
6.) Overuse of a drug(irrational
drug use & polypharmacy)
CAUSES OFERRORS
10

11. • Some other recognized types of medication
errors-
 Incomplete patient information
 Drug information unavailable
 Miscommunication of drugorders
 Confusion in drugnames
 Misuse of zeros & decimal points
 Confusion in dosingunits
 Inappropriate abbreviations
11

12. SWISSCHEESEMODEL
12
• Pictorial model formedication errors
• Defences against error displayed asthin layers
with holes that describes latent errors in system
• Eachlayer successively represents the
prescriber, pharmacist, nurse & patient related
defences
• Missed error successively at various defence
levels, reaches the patient

13. 13

14. TYPES OF MEDICATION
ERRORS
14

15. PRESCRIBINGERRORS
Incorrect drug
selection for a
patient
Errors in
quantity,
indication
Prescribing of a
contraindicated
drug
15

16. DISPENSINGERROR
16

17. DRUG ADMINISTRATION
ERRORS
Failure to check
the patient’s
identity priorto
administration
Environmental
factors such a
noise,
interruptions ,poor
lighting
Wrong calculation
to determine the
correct dose
17

18. STEPSTOBETAKENIN
PREVENTING MEDICATION
ERROR
Follow the rights of medication administration
•Right patient
•Right drug
•Right dose
•Right time
•Right route
18

19. STEPSTOBETAKENIN
PREVENTING MEDICATION
ERROR
•Right recording
•Right assessment
•Right education
•Right evaluation
•Right to refuse medication
19

20. REFERENCES
Ernawati, D. K., Lee, Y. P., & Hughes, J. D. (2014). Nature and
frequency of medication errors in a geriatric ward: an
Indonesian experience. Therapeutics and clinical risk
management, 10, 413.
European Commission (EC). (2006). Medical Errors. Retrieved
fromhttp://ec.europa.eu/public_opinion/archives/ebs/ebs_
241_en.pdf
Khowaja, K., Nizar, R., Merchant, R. J., Dias, J., Bustamante-
Gavino, I., & Malik, A. (2008). A systematic approach of
tracking and reporting medication errors at a tertiary care
university hospital, Karachi, Pakistan. Therapeutics and
clinical risk management, 4(4), 673.
20

21. REFERENCES
Stoppler,M.C.(2012).The most Common Medication Errors.
MedicineNet.com. Retrieved from
URL: http://www.medicinenet.com/script/main/art.a
sp?articlekey=55234
Singh,I., Shafiq,N.,& Malhotra, S.(2011). Medication
Errors: Causes & its prevention. Drugs Bulletin,2.
The Nation.(2011). On medical errors. Retrieved from
URL: http://www.nation.com.pk/pakistan-news-newspaper-
daily-english-online/letters/30-Dec
21