CASE PRESENTATION OF MEDICATION ERRORS - Dr Arpan Dutta Roy

1. MEDICATION ERRORS
Clinical Pharmacologist
NABH Assessor

2. MEDICATION ERROR
According to NCC MERP it can be defined as
“Any preventable event that may cause or lead to
inappropriate medication use or patient harm while
the medication is in the control of healthcare
professionals, patients or consumer”

3. MEDICATION ERROR FACTS
• Medication Error is the eighth leading cause of
death in the US.
• 7,000 Americans die annually.
• Institute of Medicine estimates 1.5 million
preventable medication errors occur each year.
• For every 100 medication errors that occur,
approximately 1% harm the patient.
• 5 serious medication errors occur for every
10,000 medications administered.

5. Types of medication errors
Medication errors can be classified into
three broad categories:
Prescribing errors
Indenting error
Dispensing errors
Drug administration errors

6. Prescribing errors
1 • Illegible handwriting
2 • Inappropriate use of decimal points
3 • Use of abbreviations
4 • Use of verbal orders
5 • Writing in small letter
6 • Inaccurate - history taking
7 • Not writing route , frequency and dose properly
8 • Not mentioning any discontinuation of dose.

7. Selection of the wrong strength / product,
wrong dose, wrong drug and wrong
patient.
Mainly caused when two or more drugs
have a similar appearance or similar
name.
(sound-alike / look-alike)
Dispensing errors

8. 1
1
Lori Diazepam 16 Ocid Omeprazole
Lorid Loratadine Ozid Pimozide
1
2
Numol Diclofenac +
Paracetamol
17 Zidmin Glipizide +
Metformin
Numox Amoxicillin+
Cloxacillin
Zidime Ceftazimide
1
3
Zenotin Ofloxacin+
Metronidazol
e
18 Pedichloryl Chloral
hydrate
Zanocin Ofloxacin Pedicloryl Trichlofos
1
4
Fepra P Paracetamol 19 Taxim Cefotaxim
Espra Esomeprazol
e
Tazin Piperacillin
1
5
Berocin Multivitamin 20 Lasix Furosemide
Zanocin Ofloxacin Laxil Lactulose

9. Look-alike Drugs

10. Some evidences of
ME (In Patients) in
some hospitals with
CAPA

11. Administering error due to sound-a-like
Medication
• Prescribed flucloxacilline but
administered fluconazole.
Identified by clinical
pharmacist.

12. • Folitrax (Methotrexate)
• Prescribed once a week
but adm OD by nurse ,
spot correction done

13. Medication error- (Missed Dose Aspirin)
Prescribed Clopitab A contain
Clopidogrel and Aspirin. But
indented and administered only
Clopidogrel. Missed dose of
aspirin.

14. Administering error due to Missed
dose-
• Eltrombopag
/Revolade
administered only 3
dose instead of 5
dose , but signature
of nurse has been
done for
administration of
medication

15. Prescribing error-
• Prescribed dose of
lorazepam was found to be
20 mg

16. Patient was advised to give " Jonac suppository" after OT & written in post operative
instruction but in medicine card it was written "Ionac 8 mg by orally".
Corrective action- It has been done by Clinical Pharmacist and also reported corrected

17. 1. Dose direction of Tab AKT-4 was written
one tab instead of one kit in the medicine
card and sister administered the same.
2. Spot correction done by ward
Clinical Pharmacist in medicine
card

18. Prescribing and Administering error due to
Illegible handwriting
3% NS saline dose missed in
cerebral oedema patient due
to illegible hand writing

19. Medication errors in discharge Medications
Some evidence

20. Therapeutic duplication ( Prescription
error)
• A medication error due to
Therapeutic duplication of
syp Dhuphalac

21. Prescription error- Wrong dose and
Duplication
Augmentin prescribed 1.5
gm( wrong dose , which is
practically available ) But
original dose is 1.2 gm .
Amoxicillin and potassium
clavulonate .

22. • Reprot of I type medication error in a
hospital (Kolkata 2016)

23. MEDICATION ERROR REPORT -

24. Medication Error Reporting Form
MAY 2 0 1 7

25. MAY 2 0 1 7
Thank you