1. Medication Errors: AMedication Errors: A
Pharmacist PerspectivePharmacist Perspective
Charles C. Sharkey M.S.M.B.A Pharm DCharles C. Sharkey M.S.M.B.A Pharm D
Pharmacy Site ManagerPharmacy Site Manager
June 2008June 2008

2. Learning Objectives:Learning Objectives:
 At the conclusion of this program theAt the conclusion of this program the
participant should be able to:participant should be able to:
 List the root causes of medication errors.List the root causes of medication errors.
 Describe the different types of medicationDescribe the different types of medication
errors.errors.
 List important strategies to preventList important strategies to prevent
medication errors.medication errors.
 Describe the costs in terms of personal andDescribe the costs in terms of personal and
monetary damages related to these errors.monetary damages related to these errors.

3. What is a Medication Error?What is a Medication Error?
 ““Any preventable event that may cause orAny preventable event that may cause or
lead to inappropriate medication use orlead to inappropriate medication use or
patient harm while the medication is in thepatient harm while the medication is in the
control of health care professional, patient,control of health care professional, patient,
or consumer”.or consumer”.
 National Coordinating Council ForNational Coordinating Council For
Medication Error Reporting and PreventionMedication Error Reporting and Prevention

4. When did the alarm bell ring?When did the alarm bell ring?
 Institute of Medicine (IOM) Report (1999)Institute of Medicine (IOM) Report (1999)
“To Err is Human: Building a Safer Health“To Err is Human: Building a Safer Health
System”System”
 44,000 to 98,000 deaths per year from44,000 to 98,000 deaths per year from
medical errors in hospitals alonemedical errors in hospitals alone
 7,000 deaths each year related to7,000 deaths each year related to
medicationsmedications

5. Highlights of the IOM ReportHighlights of the IOM Report
 Accidental injury is seriousAccidental injury is serious
 The cause is NOT CARELESS PEOPLE butThe cause is NOT CARELESS PEOPLE but
FAULITY SYSTEMSFAULITY SYSTEMS
 Need to redesign our systemsNeed to redesign our systems
 Patient Safety must be a national priorityPatient Safety must be a national priority

6. An additional perspectiveAn additional perspective
 More people die from medical mistakesMore people die from medical mistakes
each year than from highway accidents.each year than from highway accidents.
 More people die from medication errorsMore people die from medication errors
each year than workplace injuries.each year than workplace injuries.
 IOM report set the stage for reform.IOM report set the stage for reform.

7. Some famous cases in the NewsSome famous cases in the News
 Actor Dennis Quaid newborn twins received anActor Dennis Quaid newborn twins received an
accidental dose 1,000 times the intended dosageaccidental dose 1,000 times the intended dosage
of Heparin at Cedars-Sinai Medical Center.of Heparin at Cedars-Sinai Medical Center.
 Betsy Lehman health care reporter for the BostonBetsy Lehman health care reporter for the Boston
Globe died from an overdose of chemotherapy.Globe died from an overdose of chemotherapy.
She received “Cyclophosphamide 4 grams perShe received “Cyclophosphamide 4 grams per
square meter for four consecutive days instead ofsquare meter for four consecutive days instead of
4 grams per square meter over four days at the4 grams per square meter over four days at the
Dana Farber Cancer Center.Dana Farber Cancer Center.

8. Some famous cases:Some famous cases:
 1984 Libby Zion was a patient at New York1984 Libby Zion was a patient at New York
Hospital.Hospital.
 A visit to the ER quickly turned into aA visit to the ER quickly turned into a
fatality.fatality.
 Combination of meperidine plus phenelzineCombination of meperidine plus phenelzine
resulted in a serotonin syndrome.resulted in a serotonin syndrome.

9. A New Way of ThinkingA New Way of Thinking
 Michael Cohen of the nonprofit Institute ofMichael Cohen of the nonprofit Institute of
Safe Medication Practices (ISMP) saidSafe Medication Practices (ISMP) said
“finding out who was involved is less“finding out who was involved is less
important than learning what went wrong,important than learning what went wrong,
how, and why”.how, and why”.
 This comment is in the context ofThis comment is in the context of
medication errors.medication errors.

10. Humans Technology
Patient
Medication Use CycleMedication Use Cycle

11. Medication Use CycleMedication Use Cycle
 Complex systemComplex system
 Multiple layersMultiple layers
 MultidisciplinaryMultidisciplinary
 IOM Report points to the speed, andIOM Report points to the speed, and
complexity of the process in relation tocomplexity of the process in relation to
errorserrors

12. Medication Use CycleMedication Use Cycle
 PatientPatient
Expectation of safe and compassionate careExpectation of safe and compassionate care
Trust and confidence in healthcare providersTrust and confidence in healthcare providers
Expect a trouble free stayExpect a trouble free stay

13. Medication Use CycleMedication Use Cycle
 Human factorsHuman factors::
Humans by nature are vulnerable to errorHumans by nature are vulnerable to error
Healthcare workers are highly trained andHealthcare workers are highly trained and
dedicated.dedicated.
Errors occur because of the systems in whichErrors occur because of the systems in which
they work.they work.

14. Medication Use CycleMedication Use Cycle
 TechnologyTechnology
Automate repetitive, time-consuming, errorAutomate repetitive, time-consuming, error
prone tasksprone tasks
IOM report emphasizes that “all technologyIOM report emphasizes that “all technology
introduces new errors even when its soleintroduces new errors even when its sole
purpose is to prevent errors.”purpose is to prevent errors.”

15. Nodes of Medication UseNodes of Medication Use
ProcessProcess
 PrescribingPrescribing
 DocumentingDocumenting
 AdministrationAdministration
 MonitoringMonitoring

16. Look Alike / Sound Alike NamesLook Alike / Sound Alike Names
 Carboplatin vs. cisplatinCarboplatin vs. cisplatin
 Celexa vs. Celebrex vs. CerebyxCelexa vs. Celebrex vs. Cerebyx
 Folic acid vs. Folinic acidFolic acid vs. Folinic acid
 Hydroxyzine vs. HydralazineHydroxyzine vs. Hydralazine
 Quinine vs. QuinidineQuinine vs. Quinidine
 Vinblastine vs. VincristineVinblastine vs. Vincristine

18. Confusing Abbreviations andConfusing Abbreviations and
SymbolsSymbols
 AZT = Zidovudine vs. Azathioprine vs.AZT = Zidovudine vs. Azathioprine vs.
AztreonamAztreonam
 5-FU = Fluorouracil vs. Flucytosine5-FU = Fluorouracil vs. Flucytosine
 QD or OD = Once daily vs. right eyeQD or OD = Once daily vs. right eye
 IU = International units vs. IVIU = International units vs. IV

19. Incorrect Route of AdministrationIncorrect Route of Administration
 Misinterpretation of IM, IV, or IntrathecalMisinterpretation of IM, IV, or Intrathecal
 Vincristine vs. VinblastineVincristine vs. Vinblastine
 Fatal outcomesFatal outcomes

21. Packaging / Labeling of aPackaging / Labeling of a
ProductProduct
 Poor DesignPoor Design
 Similar package colors or sizeSimilar package colors or size
 Crowding of information on the labelsCrowding of information on the labels

27. Physical Arrangement ofPhysical Arrangement of
MedicationsMedications
 Storage of medications side by side withStorage of medications side by side with
similar names or strengths.similar names or strengths.
 Medications placed in the wrong spot.Medications placed in the wrong spot.

30. Timing of MedicationsTiming of Medications
 Errors of omissionErrors of omission
 Wrong time errorsWrong time errors

31. High Alert MedicationsHigh Alert Medications
 Safe guards in the system for high riskSafe guards in the system for high risk
medications.medications.
 VHA DirectivesVHA Directives

34. Interpretation of DosagesInterpretation of Dosages
 Calcium Gluconate - mEq, or mgs ofCalcium Gluconate - mEq, or mgs of
calciumcalcium
 Potassium Phosphate - millimoles or mgs ofPotassium Phosphate - millimoles or mgs of
phosphorousphosphorous
 Acetaminophen elixir vs. dropsAcetaminophen elixir vs. drops

35. Prescriber Order EntryPrescriber Order Entry
 Choose the correct drug in the correct form.Choose the correct drug in the correct form.
 Menus to chose from must be user friendly.Menus to chose from must be user friendly.
 Allergy defense system.Allergy defense system.

37. Informational Needs:Informational Needs:
 Unavailable patient informationUnavailable patient information
Diagnoses, lab values, allergiesDiagnoses, lab values, allergies
 Unavailable drug informationUnavailable drug information
Drug interactions, dosages, new productsDrug interactions, dosages, new products

38. Contributing Factors ForContributing Factors For
Medication ErrorsMedication Errors
 Physical work environmentPhysical work environment
 Environmental stressEnvironmental stress
 Drug delivery servicesDrug delivery services

39. A Word about Pediatric MedicationA Word about Pediatric Medication
ErrorsErrors
 Most medications are packaged for adultsMost medications are packaged for adults
 Most health care institutions are built aroundMost health care institutions are built around
the needs of adultsthe needs of adults
 Children are less able to tolerate the effectsChildren are less able to tolerate the effects
of an errorof an error
 Children are less able to communicateChildren are less able to communicate
effectively if an error occurseffectively if an error occurs

40. What does the Joint CommissionWhat does the Joint Commission
(JCAHO) have to say?(JCAHO) have to say?
 Identify the top five high alert medicationsIdentify the top five high alert medications
 InsulinInsulin
 Opiates, and narcotics.Opiates, and narcotics.
 Potassium Chloride and PhosphatePotassium Chloride and Phosphate
 Heparin/warfarinHeparin/warfarin
 Sodium Chloride concentrateSodium Chloride concentrate

41. JCAHO and Sentinel EventsJCAHO and Sentinel Events
 Sentinel event is “an unexpectedSentinel event is “an unexpected
occurrence involving death or seriousoccurrence involving death or serious
physical or psychological injury or the riskphysical or psychological injury or the risk
there of”.there of”.
 Some medication errors will fit thisSome medication errors will fit this
definition.definition.
 Requires a more thorough analysis.Requires a more thorough analysis.

42. JCAHO-How do we do the analysis?JCAHO-How do we do the analysis?
 Root cause analysis (RCA)Root cause analysis (RCA)
 Failure Mode Effect Analysis (FMEA)Failure Mode Effect Analysis (FMEA)
 The bottom line here is to “drill down” andThe bottom line here is to “drill down” and
consider all factors involved with theconsider all factors involved with the
processprocess

43. Strategies To Prevent MedicationStrategies To Prevent Medication
ErrorsErrors
Institute of Medicine (IOM) ReportInstitute of Medicine (IOM) Report
 Prioritization of safety as a goalPrioritization of safety as a goal
 High levels of redundancyHigh levels of redundancy
 Continuous trainingContinuous training
 High-level organizational learningHigh-level organizational learning

44. JCAHO and MedicationJCAHO and Medication
ReconciliationReconciliation
 ““Process of comparing a patientsProcess of comparing a patients
medication orders to all of the medicationsmedication orders to all of the medications
that the patient has been taking”.that the patient has been taking”.
 Medication Reconciliation must occur atMedication Reconciliation must occur at
each point of transition in careeach point of transition in care
 Newest strategy to prevent medicationNewest strategy to prevent medication
errors.errors.

45. Strategies to PreventStrategies to Prevent
Medication ErrorsMedication Errors
 Force functions and constraintsForce functions and constraints
 Automation and computerizationAutomation and computerization
 Drug protocolsDrug protocols
 Double checking by staffDouble checking by staff
 Policies on medication usePolicies on medication use
 EducationEducation

46. Strategies To Prevent MedicationStrategies To Prevent Medication
ErrorsErrors
 System analysisSystem analysis
 Multidisciplinary planningMultidisciplinary planning
 Collect information on Medication errorsCollect information on Medication errors
 Develop action plansDevelop action plans
 Design systems for recoveryDesign systems for recovery
 Learn from mistakesLearn from mistakes

47. Food and Drug Administration (FDA)Food and Drug Administration (FDA)
Role in Medication ErrorsRole in Medication Errors
 Collect and Analyze DataCollect and Analyze Data
 Bar Code Labeling Rule (2003)Bar Code Labeling Rule (2003)
 Drug Nomenclature review of new productsDrug Nomenclature review of new products
 Drug Facts LabelingDrug Facts Labeling
 Public EducationPublic Education

50. Medication Errors: What’s atMedication Errors: What’s at
Stake?Stake?
 Patient injuryPatient injury
 Staff injuryStaff injury
 Loss of confidenceLoss of confidence
 Economic costsEconomic costs

51. A Final WordA Final Word
 The Organization you practice pharmacy inThe Organization you practice pharmacy in
must adopt a “Culture of Safety” approachmust adopt a “Culture of Safety” approach
in all patient care activities.in all patient care activities.
 There is no “quick fix” to the problem.There is no “quick fix” to the problem.
 Failure to do can result in catastrophic costsFailure to do can result in catastrophic costs
in economic, emotional, and personal terms.in economic, emotional, and personal terms.

52. QuestionsQuestions
 Questions????Questions????