MEDICATION ERROR

1. In the name of Allah, Most
Gracious, Most
Merciful.

2. STRATEGIC PLAN TO
MINIMIZE MEDICATION
ERROR
By
Mr.Jawed Ali Quazi

3.  Define medication errors and classify their
significance
 Understand the extent of medication errors
and their impact on patient care
 Discuss the many factors that contribute to
errors and the impulse to “place blame” on
healthcare workers
 Examine approaches to minimize the risk of
medication errors

4. "A medication error is any preventable event that
may cause or lead to inappropriate medication use
or patient harm while the medication is in the
control of the health care professional, patient, or
consumer. Such events may be related to:
National Coordinating Committee-Medication Error Reporting and Prevention (NCC MERP); accessed at
http://www.nccmerp.org/aboutMedErrors.html; Jan. 2012.
• professional practice
• health care products
• procedures and systems
• product labeling, packaging,
and nomenclature
• dispensing
• distribution
• administration
• education
• monitoring

5. Medication Errors in 1,116 Hospitals
Medication Error (Overall)
430,586
5.07% (of admission)
1 error every 22.7 hr
1 every 19.7 admission

6.  found 616 medication errors (5.7%),
 115 potential ADEs (1.1%), and 26 ADEs
(0.24%). Of the 26 ADEs, 5 (19%) were
preventable.
 Most potential ADEs occurred at the stage of
drug ordering (79%)
 The rate of potential ADEs was significantly
higher in neonates in the neonatal intensive
care unit.
 Ref: JAMA. 2001;285(16):2114-2120. doi:10.1001/jama.285.16.2114
Reviewed 10 778 medication orders

7. Extra Extra
Airlines expect 1-2
jets to crash daily
Over 1000 deaths expected weekly

8. Kohn et al. Committee on quality health care in America. IOM. Academy Press. 1999.
Extra Extra
Airlines expect 1-2 jets to
crash daily
Over 1000 deaths expected
weekly
=
44,000 – 98,000
deaths annually
due to
medical errors

9. A Comparison of Risks
 Risk (per flight) of dying in a commercial
airline accident
1 in 8 million*
 Risk (per hospital admission)
of dying from a medical error >1 in 1,000
*1 in 2 million from 1967-1976

10. Accidents
123,706
Medical
Errors
~100,000
Alzheimer's
74,632
Diabetes
71,382
www.cdc.gov/nchs/fastats. Accessed Jan 2012. Based on 2007 data.
How medical errors rank as cause
of mortality
Heart
616,067
Cancer
562,875
Stroke
135,952
Lung
127,924

11. NCC MERP. accessed Jan 2012. www.nccmerp.org
Classifying medication errors
A circumstances exist for potential errors to occur
B an error occurred but did not reach the patient
C error reached the patient but did not cause harm
D patient monitoring required to determine lack of harm
E error caused temporary harm and some intervention
F temporary harm with initial or prolonged hospitalization
G error resulted in permanent patient harm
H error required intervention to sustain the patient’s life
I error contributed to the patient’s death

13. Medication
Errors 19.4%
Diagnostic,
8.1%
Therapeutic,
7.5%
Procedure
Related, 7%
Others,10.3%

14. Ordering/
Prescribing 39%
Administration
38%
Dispensing 12%
Transcribing
11%

15. Some reasons errors occur
• poor communications within healthcare team
• verbal orders
• poor handwriting
• improper drug selection
• missing medication
• incorrect scheduling
• look alike / sound alike drugs
• polypharmacy
• availability of floor stock (no second check)
• drug interactions
• hectic work environment
• lack of computer decision support

16.  Calculation errors
 Improper use of zeros & decimal points
 Inappropriate use of abbreviations
 Careless prescribing
 Illegible handwriting
 Missing information
 Drug product characteristics
 Compounding /drug preparation errors
 Prescription labeling
 Work environment & personnel issues
 Deficiencies in medication use systems

17. Medication Errors, Who Makes Them?
Physician Pharmacist Nurse Patient
Any
member of
the health
care team

18. 432
509
432
599
555
432
338
444
376
400
326
300
338
462
449
397
379
300
288
309314
282
322
335
0
100
200
300
400
500
600
700
Month 1Month 2Month 3Month 4Month 5Month 6Month 7Month 8Month 9Month 10Month 11Month 12
1434 1435

19. 0
20
40
60
80
100
120
140
160
180
Medical
Surgical
Ortho
Chest
Cardiology
ENT
Ophthalmology
Peadia
Urology
Dermatology
AKU
Emergency
OBG/LR
Dental
Neurology
Psychiatric clinic

20. 0
20
40
60
80
100
120
140
160
180
No Diagnosis Prohibited
Abbr
No Gen Name Prescription
Previlage
No.file No. weak
strenght
No Diagnosis
Prohibited Abbr
No Gen Name
Prescription Previlage
No.file No.
weak strenght
MOST COMMON ERROR TOTAL NO. OF ERROR QUARTER
No Diagnosis
148
Prohibited Abbr 80
No Gen Name
168
Prescription Previlage 57
No.file No. 98
Weak Strength 57

25. An anticonvulsant
approved in Canada and the US
since2005 to treat neuropathic pain
approved by the European
Commission in 2006 to treat
generalized anxiety disorder.
 The maximum dose of pregabalin
depends on its indication but should
not exceed 600 mg/day.

26. Clinical studies including 5500 patients
showed that euphoric effects were reported
more frequently in pregabalin groups versus
placebo (4% vs. 1%, respectively).
A clinical abuse liability study found that
pregabalin had a potential for euphorigenic
activity in susceptible populations.
Therefore scheduled by the US Drug
Enforcement Administration under the
Controlled Substances Act as a Schedule V
drug, indicating that
it had abuse potential.

27. Emerg Med J 2013;30:874 doi:10.1136/emermed-2013-203113.20
•Abstracts
Lyrica Nights–recreational Pregabalin
Abuse In An Urban Emergency Dept
Author Affiliations
1.Emergency Department, Royal Victoria Hospital, Belfast, United
Kingdom
"Pregabalin Abuse, Dependence, and Withdrawal: A
Case Report." The American Journal of Psychiatry,
167(7), p. 869

28. No Medical Reconciliation
Computer Operated Entry
Hospital File Number
Prescribing Privilege

29. Reconciliation: A process of identifying the
most accurate list of all medications a
patient is taking—including name, dosage,
frequency, and route.
Requires comparing the patient’s list of
current medications against the physician’s
admission, transfer, and/or discharge
orders
Needs even for OPD patients by MOH
http://www.ihi.org/NR/rdonlyres/598D427A-4BDA-419D-91B5-
B836D23A6F1D/0/CampaignOverview101105.ppt#358,9,Prevent Adverse Drug Events by Implementing Medication
Reconciliation

31. ZANTAC (Ranitidine 150mg)
ZINNAT (Cefuroxime 250mg
tablet/ susp )
Generic Name
Diagnosis

32.  Factors:
 health status of patients
 magnitude of overdose
 damage as result of omission
 Financial Implications
 prolong hospital stays & increase health care
expenses
 estimated to cost billions of dollars annually
 additional medical management

33. Sources of Error
• Prescribing error - selecting the wrong or
inappropriate drug/dose/formulation/duration etc
• Communicating those instructions
• Supply error - timely; wrong drug, dose, route;
expired medicines, labelling.
• Administration error - timing; wrong route; wrong
rate/technique.
• Lack of user education - actions to take.

34. MEDICATION ERROR
PREVENTION
Prescribers
Avoid
illegible
Handwriting
Minimize
Telephone &
Verbal orders
Document
Drug Allergies
Familiar With
medication
Order system
Update drug
knowledge

37.  “AZT” for zidovudine (Retrovir)
 could be azathioprine (Imuran)
 “U” HAS been mistaken for “zero”(o)
 10 U insulin order & patient received 100 insulin
units
 “QD” has been read as “QID” or “OD”
 DO NOT USE Lists
 The Joint Commission
 Institute for Safe Medication Practices (ISMP

40.  Decimal point errors cause significant
consequences
 Decimal point errors occur
 result of miscalculation
 when writing orders or instructions
 result of artifact on faxed order
 Always write leading zero in front of
number < 1
 Never write trailing zeros

43.  e-Prescribing Systems:
 Reduced medication errors by 85%
 Net cost savings of $403,000 in ambulatory care settings22,23
 Bar Code Electronic Medication Administration System (eMAR)
Technology:
 51% reduction in medication errors
 Annual savings of $2.2 million in a large academic hospital24,25
• Computerized Physician Order Entry
(CPOE):
– Reduced serious medication errors by 81%26
Notes
22. Kaushal, R., Kern, L.M., Barrón, Y., et al. (2010). Electronic prescribing improves medication safety in community-based office practices. J Gen Intern Med, 25(6), 530-536.
23. Weingart, S.N., Simchowitz, B., Padolsky, H., et al. (2009). An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and
cost in ambulatory care. Arch Intern Med, 169(16), 1465-1473.
24. Poon, E.G., Keohane, C.A., Yoon, C.S., et al. (2010). Effect of bar-code technology on the safety of medication administration. N Engl J Med, 362(18),1698-1707.
25. Maviglia, S.M., Yoo, J.Y., Franz, C., et al. (2007). Cost-benefit analysis of a hospital pharmacy bar code solution. Arch Intern Med, 167(8), 788-794.
26. Bates, D.W., Teich, J.M., Lee, J., et al. (1999). The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc, 6(4), 313-321.

44. Clinical Effectiveness of Safe Practices
Intervention Results
Physician computer order entry 81% reduction of medication
errors
Pharmacist rounding with team 66% reduction of preventable
adverse drug events; 78%
reduction of preventable adverse
drug events
Rapid response teams Cardiac arrests decreased by 15%
Team training in labor and delivery 50% reduction in adverse
outcomes in preterm deliveries
Reconciling medication practices
upon hospital discharge
90% reduction in medication
errors

45.  Failure to include concentration in
prescription can result in wrong dose being
dispensed
 amoxicillin suspension 1/2 tsp (2.5 mL) TID
 Concentration?
 “1 amp,” “1 vial,” “1 cap” unclear
 multiple strengths, doses, or vial sizes
 Order for one “vial” of magnesium sulfate?
 2 mL vial (8 mEq)
 20 mL vial (16 mEq)
 10 mL vial of 50% concentration (40 mEq)

46.  Handwriting of physicians is subject of jokes
 no laughing matter
 Unclear orders should be clarified
 Use standardized, preprinted order forms
 Computer generated & typewritten labels
 Use of upper- and lowercase lettering
(TALLman)

47.  Lack of medical information about patient
may cause error
 age
 weight
 allergies
 diagnosis
 indication & severity of condition

48.  Error is inevitable due to “our” limitations:
- limited memory capacity
- limited mental processing capacity
- negative effects of fatigue other stressors
 We all make errors all the time
 Patients suffer adverse events much more
often than previously realised
 Errors often NOT immediately observed

49. Human beings will always make
errors
Errors are common in medicine,
killing tens of thousands
Naming, blaming and shaming
have no remedial value

50. THANK YOU