1. Medication Errors:
Focus on Prevention Tactics
Gary Brodskiy
PharmD/MBA Candidate, Anticipated 2017
Fairleigh Dickinson University School of Pharmacy and Health Sciences
August 24, 2016

2. Objectives
• Differentiate between a medication error, adverse
drug event, and adverse drug reaction
• Identify common causes of medication errors and
approaches to prevent them
• Assess novel modification to the five “rights”
required for safe medication ordering
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3. Background
• 700,000 emergency department visits and 120,000
hospitalizations are due to ADEs annually
• $3.5 billion is paid out on extra medical costs of
ADEs annually
• At least 1.5 million preventable ADEs occur in the
United States each year
• At least 40% of costs of ambulatory ADEs are
estimated to be preventable
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4. Definitions
• Medication error
– Error at any step along the pathway that begins when
a clinician prescribes a medication and ends when the
patient receives the medication
• Preventable ADE
– Medication error that reaches the patient and causes
any degree of harm
• ADR (side effect or non-preventable ADE)
– ADE that is experienced when a medication is
prescribed and administered appropriately
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5. Examples of Illegible Handwriting
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6. Common Causes of Medication Errors
• Drug product
nomenclature
(i.e. LASA names)
• Equipment failure or
malfunction
• Illegible handwriting
• Improper transcription
• Inaccurate dosage
calculation
• Inadequately trained
personnel
• Inappropriate
abbreviations
• Labeling errors
• Excessive workload
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7. Does It Stop There?
• Even though many medication errors are
preventable, they will never be eliminated
• The number of ADEs will likely grow due to:
– Aging population
– Increase in use of medication for disease prevention
– Discover new uses for existing medication
– Development of new medications
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8. Technical Approaches to Preventing Errors
• Prescribing errors
– Computerized physician order entry system (CPOE)
– Clinical decision support system (CDSS)
– E-scribing
• Preparation errors
– Pill counters
– Unit-dose packagers
– IV compounding robots
• Dispensing errors
– Carousels
– Automated dispensing cabinets (ADCs)
• Administration errors
– Electronic medication administration record (eMAR)
– Bar code medication administration system (BCMA)
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9. CPOE
• Computer system that replaces traditional methods
of placing orders (i.e. written and verbal) and
ensures legible orders
• Functionality of CPOE is increased by adding CDSS
– Provides clinicians decision support in real-time as they
enter electronic orders
– Examples: drug interactions, patient allergies,
medication contraindications, renal- and weight-based
dosing, etc.
• CPOE is one of CMS’s criteria for electronic medical
record’s “meaningful use”
– Meant to ensure active incorporation into patient care
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10. Advantages of CPOE with CDSS
• Free of handwriting identification problems
• Easily linked to drug-drug interactions
• Link to ADE reporting systems
• Avoid specification errors (i.e. trailing zeros)
• Emphasize cost-effective medications
• Reduce incorrect drug choices
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11. Impact of CPOE on Pharmacists
• Clinical Informatics
– Manage medication related information while
promoting integration, interoperability, and information
exchange
– Cataloging and embedding knowledge into the
workflow
– Develop analytic solutions for improving decision-
making
– Apply user experience for optimizing clinical practice
and usability
• Efficiency in workflow
– Spend less time per day clarifying medication orders
– Concentrate on clinical aspects of the medication
ordering process
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12. McMullen et al. (2015)
• Purpose: investigate pharmacists’ satisfaction with
CPOE system and the impact of CPOE on pharmacy
workflow in three hospitals of a large Michigan-
based health system
• Methods: Evaluate how CPOE implementation
affects pharmacists through:
– Self-reported perceptions of CPOE implementation
– Description of experiences through interviews and focus
groups
– Frequency and duration of pharmacists’ work clarifying
orders before and after implementation
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14. • Quicker order verification
• Better prioritization of orders
• Increased mobility through hospital
• Reduction of orders requiring clarification
Benefits from McMullen et al.
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15. • Short follow-up period demonstrates CPOE
benefits only over a short term
• Studied only one hospital system and one
EHR vendor, making it difficult to generalize
• CPOE’s impact on workflow limited by only
observing medication clarification events
Limitations of McMullen et al. Study
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16. Conclusion from McMullen et al.
“Pharmacists noted that order ambiguity still
existed and that the system needed to be
optimized to gain efficiencies and increase
clarity.”
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17. Is CPOE a Solution?
• Success of CPOE
– Processing drugs via CPOE decreases likelihood of error
drug order by 48%
– In 2008, estimate of 12.5% reduction in medication errors
or ~17.4 million errors averted in USA
• Downfall of CPOE
– NOT a solution for medication errors
– Personalized order sets which may deviate from
protocols
– Ambiguity still exists
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18. Joyce Oyler Case (2013)
• The 66 year-old female was treated for CHF at Heartland
Regional Medical Center in St. Joseph, Missouri
• Hospital nurse telephones eight new prescriptions to local
pharmacy
• Transcribing error occurred when methotrexate was listed
instead of metolazone
• Heartland’s home health care agency was required by
Medicare to ensure all drugs matched prescriptions ordered
• Error in transition of care resulted in:
– Sores developing in her mouth and throat and blood seeping
from nose and bowels  required hospitalization
– Irreparably damaged bone marrow’s ability to create blood
cells
– Death from multiple organ failure
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19. Reduce Errors Associated with Verbal Orders
• Do NOT permit verbal
orders for antineoplastic
agents due to narrow margin
of safety
• Clear communication of
content
• E-scribing?
– Incorrect drug selection from
pull down menu
– Typing MET, 2.5
– Custom directions
• Provide indication for use
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20. The Five “Rights”
Right Patient
Right Drug
Right Dose
Right Route
Right Time
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21. Schiff et al. (2016)
• Add a sixth element to the five “rights”
required for safe medication ordering  right
indication
• Propose to shift medication ordering workflow
to indications-based prescribing where
medication choices are narrowed to indications
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22. Potential Benefits of “Sixth” Right
• Improve medication safety
– Identify and intervene wrong-drug errors
– Ensure proper dosing regimen
• Better educate and empower patients
– Facilitate patient adherence due to better understanding
– Enhance shared decision making and encourage
questions
• Streamline reimbursement coding
• Improve health care team communication
– Aid care transitions by providing reasons for
medications
– Provide information to help counsel patients
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23. Potential Benefits of “Sixth” Right
• Facilitate medication reconciliation
– Organize list by indication
– Knowing reason of why started helps decide whether to
discontinue
• Increase efficiency of prescribing by showing drug
regimen choices for indication
• Improve documentation of medical history
• Improve appropriate use of medication by prescribers
– Reduce “never-indicated” drugs
– Support selection of targeted drug choices
• Accurately measure a drug’s long-term effectiveness
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24. Potential Challenges of “Sixth” Right
• Extra prescriber time and effort
• Privacy concerns
• No randomized trials showing use of indications is
beneficial
• Defining and creating indications is complex
– Terminology (ICD-10, diagnosis, symptom, etc.)
– Drugs given for multiple indications
– Empirical treatment that lacks definite diagnosis
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25. Potential Challenges of “Sixth” Right
• Creating “smart” drug recommendations based on
indications
– Need to incorporate allergies, contraindicated diseases,
etc.
– Ensure that choices do not include previous drugs that
have failed
– Inclusion of insurance and formulary requirements
• Transmission of indication information from
CPOE to pharmacy to patient
– Interoperability between EHR and pharmacy system
– Limited real estate on prescription labels
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26. Conclusion and Future Research of “Sixth” Right
• Knowledge of indications is key to getting prescribers,
pharmacists, nurses, and patients on the same page
regarding what is being treated and outcomes desired
• Agency for Healthcare Research and Quality (AHRQ)
funded a 3-year project with key stakeholders for seven
international Web conferences
– Clarify rationale behind “sixth” right model
– Challenges to implementation of model
– Find ways to move the model forward
• Researchers are currently working with engineers, IT design
specialists, and policy leaders to build a prototype
– Objective: system will result in a safer and more efficient way
of ordering medications
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27. Capital Health CPOE & “Sixth” Right
• Benefit to attendings and residents
– Eliminates time spent researching recommended drug
choice and proper dosing regimen
• Benefit to pharmacy
– Decreases time spent clarifying orders, thus increasing
availability for other tasks
– Optimize medication reconciliation by eliminating the
need to guess indication and ensuring reason for
discontinuation
• Increase probability of cost savings for both
hospitals through clinical utilization
– HCPs doing the right things in the right way
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28. Future of Medication Error Prevention
• Patient care is shifting to a team-based approach so
a collaborative work environment combined with
safety-focused leadership is a key element of
providing quality care
• Implementation of information technology systems
are vital components of strategies to prevent
medication errors so there is a need for continuous
improvement
• No solution, but combining team-based patient care
with continuous technical improvements can have
the potential to significantly minimize errors
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30. References
• https://psnet.ahrq.gov/primers/primer/23/medication-errors
• Slone Epidemiology Center at Boston University. Patterns of
medication use in the United States, 2006.
• Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB,
Schroeder TJ, Annest JL. National surveillance of emergency
department visits for outpatient adverse drug events .External
Web Site Icon JAMA 2006;296:1858-66.
• Institute of Medicine. Committee on Identifying and Preventing
Medication Errors. Preventing Medication Errors, Washington,
DC: The National Academies Press 2006
• Aspden P, Wolcott JA, Bootman JL, Cronenwett LR, eds.
Preventing medication errors. Committee on
• Identifying and Preventing Medication Errors, Institute of
Medicine. Washington, DC: National Academies Press, 2006.
• https://healthit.ahrq.gov/sites/default/files/docs/page/09-
0031-EF_cpoe.pdf
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869307/
• https://www.ashp.org/DocLibrary/BestPractices/AutoITStInf
ormatics.aspx
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