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Medication error

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Medication error

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Medication error

  1. 1. Medication error S.Parasuraman M.Pharm., Ph.D., Editor-in-Chief, JYP, JPNR, Unit Head of Pharmacology, FOP, AIMST University, Malaysia.
  2. 2. 4/19/2018 2
  3. 3. Medication errors • Medication errors are common medical faults leading to adverse effects in patients. • 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 professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use." Medication Errors - World Health Organization. 2016. http://apps.who.int/iris/bitstream/handle/10665/252274/9789241511643-eng.pdf;jsessionid=590D0A8916645680E1E2B0B138366328?sequence=1 4/19/2018 3
  4. 4. From the literature: • Bates et al., reported that, MEs prolong hospital stays by 2 days and increase the costs by $2,000–$2,500 per patient. • Vazin et al., reported 37.6% of administration, 21.1% prescription and 10.0% transcription errors in Shiraz University of Medical Sciences, Iran. • Rothschild et al., observed 0.078 errors per patient, and 0.029 errors per medication. Highest rate of errors pertained to dosing errors, drug omission, and wrong frequency errors. • Bates et al. J Gen Intern Med. 1995;10(4):199–205.; Vazin et al. Drug Healthc Patient Saf. 2014 ;6:179-84.; Rothschild et al. Ann Emerg Med. 2010;55(6):513–521. 4/19/2018 4
  5. 5. From the literature: • Dr. Barbara statistics showed the number of mortality due to hospital administration, which is given below: – 12,000 die from unnecessary surgery – 7,000 die from medication errors in hospitals – 20,000 die from other errors in hospitals – 80,000 die from hospital-acquired infections – 106,000 die from the negative side effects of drugs taken as prescribed • Starfield B. JAMA. 2000 ;284(4):483-5.4/19/2018 5
  6. 6. ME in INDIA • Last accessed on 11/04/2018 4/19/2018 6
  7. 7. ME in INDIA One in 10 hospital admissions leads to an AE One in 300 admissions in death Unsafe practices associated with 70% of the injections administered • Last accessed on 11/04/2018 4/19/2018 7
  8. 8. Classification of medication errors based on a psychological approach Ref: Aronson JK. Medication errors: definitions and classification. Br J Clin Pharmacol. 2009 Jun;67(6):599-604 4/19/2018 8
  9. 9. Classification of medication errors Type of error Example Mistakes knowledge • Giving penicillin (without estimating allergy) • interaction between warfarin and erythromycin (warfarin toxicity) rule-based mistakenly applying a good rule applying bad rule Excessive doses of captopril Skill-based errors action-based Intending to write ‘chlorpromazine’ but instead writing ‘chlorpropamide’. technical errors • Wrong amount of acetylcesteine in an infusion bottle • Writing illegibly, so that ‘Panadol’ (paracetamol) is dispensed instead of ‘Priadel’ (lithium) memory-based Giving penicillin, to patient with know history of allergy. Maximum daily : ‘as required’ Ferner RE, Aronson JK. Drug Saf. 2006;29(11):1011-22.; Aronson JK. QJM. 2009;102(8):513-21. 4/19/2018 9
  10. 10. Causes of medication errors • Factors associated with – health care professionals • Prescription: prescription errors, including Illegible handwriting, irrational, inappropriate, and ineffective prescribing • Dispensing the formulation: wrong drug, wrong formulation, wrong label – Patients • Taking the drug: wrong dose, wrong route, wrong frequency, wrong duration – the work environment – Medicines – tasks – computerized information systems – Primary-secondary care interface 4/19/2018 10
  11. 11. Causes of medication errors • Factors associated with health care professionals – Lack of therapeutic training – Inadequate drug knowledge and experience – Inadequate knowledge of the patient – Inadequate perception of risk – Overworked or fatigued health care professionals – Physical and emotional health issues – Poor communication between health care professional and – with patients 4/19/2018 11
  12. 12. Causes of medication errors • Factors associated with health care professionals Can You read from this?4/19/2018 12
  13. 13. Causes of medication errors • Factors associated with health care professionals Always use leading zero for decimal points4/19/2018 13
  14. 14. Causes of medication errors • Factors associated with health care professionals 4/19/2018 14
  15. 15. Causes of medication errors • Factors associated with health care professionals https://www.dailyrounds.org/blog/write- prescriptions-legibly-preferably-in-capital- letters-new-mci-rule-for-doctors/ 4/19/2018 15
  16. 16. Causes of medication errors • Factors associated with health care professionals https://www.dailyrounds.org/blog/write- prescriptions-legibly-preferably-in-capital- letters-new-mci-rule-for-doctors/ 4/19/2018 16
  17. 17. Causes of medication errors • Factors associated with health care professionals Midazolam - Benzodiazepines Pantoprazole - Proton pump inhibitors 4/19/2018 17
  18. 18. Causes of medication errors • Factors associated with health care professionals Valsartan - Angiotensin II Receptor Blockers Divalproex - Anticonvulsant 4/19/2018 18
  19. 19. Causes of medication errors • Factors associated with health care professionals 4/19/2018 19
  20. 20. Causes of medication errors • Factors associated with health care professionals How labels, packages, and medicine names can cause confusion and errors 4/19/2018 20
  21. 21. Causes of medication errors • Factors associated with health care professionals Wrong identification of drug 4/19/2018 21
  22. 22. Causes of medication errors • Factors associated with patients – Patient characteristics – Complexity of clinical case, including multiple health conditions, polypharmacy and high-risk medications 4/19/2018 22
  23. 23. How to minimize the ME • Educating health care providers and patients • Implementing medication reviews and reconciliation • Using computerized systems • Prioritizing areas for quick wins 4/19/2018 23
  24. 24. How to minimize the ME • Educating health care providers and patients • Prescribers: – use sound med reconciliation techniques • Use plain language; Avoid medical jargon, Speak slowly, Brank info, down into short statements, use visual aids – avoid verbal orders except in emergencies Sound alike medications Clotrimazole – Co-trimoxazole Oxycontin – Oxynorm (Oxycodone) Dopamine – Dobutamine Adrenaline – Atropine Noradrenaline – Adrenaline 4/19/2018 24
  25. 25. How to minimize the ME • Educating health care providers and patients • Prescribers: – avoid abbreviations (U for units seen as a 0) – inform patients of reasons for all medications – work as a team with consultant pharmacists and nurses – use special caution with high-risk medications – report errors and ADEs Abbreviations Intended Meaning Misinterpretation Correction µg Microgram Mistaken as “mg” Use “mcg” BT Bedtime Mistaken as “BID” Use “bedtime” IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or “NAS” 4/19/2018 25
  26. 26. How to minimize the ME • Educating health care providers and patients • Pharmacists: – monitor the medication safety literature – follow a medication error (avoidance plan) – verify the accurate entry of data on new prescriptions (avoid abbreviations; use TALLman lettering) – report errors 4/19/2018 26
  27. 27. How to minimize the ME • Educating health care providers and patients • Nurses: – foster a commitment to patients’ – be prepared and confident in questioning medication orders – Participate/ lead in evaluations of the efficacy of new safety systems and technology – support a culture that values accurate reporting of medication errors Preventing Medication Errors: Quality Chasm Series. accessed 2010. www.nap.edu/catalog/11623.html. 4/19/2018 27
  28. 28. How to minimize the ME • Implementing medication reviews and reconciliation Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital. Refer: http://www.ihi.org/Topics/ADEsMedicationReconciliation/Pages/default.aspx [Last accessed on 15/04/2018]4/19/2018 28
  29. 29. How to minimize the ME • Using computerized systems e-Rx Parrish Ii RH. Pharmacy (Basel). 2015;4(1). pii: E2.4/19/2018 29
  30. 30. How to minimize the ME • Using computerized systems e-Rx 4/19/2018 30
  31. 31. How to minimize the ME • Using computerized systems e-Rx 4/19/2018 31
  32. 32. How to minimize the ME • Prioritizing areas for quick wins Act Plan DoStudy 4/19/2018 32
  33. 33. Reporting of ME MEDICATION ERROR REPORTING SYSTEMS – LESSONS LEARNT (FIP) https://www.fip.org/files/fip/Patient%20Safety/Medication%20Error%20Reporting%20-%20Lessons%20Learnt2008.pdf Last accessed on 10/04/2018 4/19/2018 33
  34. 34. Reporting of ME A man who injected four patients with contaminated penicillin leading to their deaths at the New Senchi Health Centre The Food and Drugs Authority (FDA) explains that a system which aims at improving healthcare delivery and to prevent medication errors Two of the victims of the fatal injections Ref: https://www.myjoyonline.com/lifestyle/2018/april-4th/senchi- deaths-fda-reveals-medication-errors-are-not-punishable.php [Last accessed on 15/04/2018] 4/19/2018 34
  35. 35. Understanding the causes of medication errors and how to reduce them @Source: http://www.pmlive.com/pharma_intelligence/The_Patient_Safety_Challenge_1226196 [Last accessed on 15/04/18] 4/19/2018 35
  36. 36. Example for Medical jargon BP: Blood pressure FX: Bone fracture JT: A joint NPO: Not take anything by mouth IM: Intramuscular Back 4/19/2018 36
  37. 37. Tall Man lettering Back Use a combination of lower and upper case of lower and upper case letters to highlight the differences between look-alike, sound-alike medicine names chlorproMAZINE chlorproPAMIDE cycloSERINE cycloSPORINE TOLAZamide TOLBUTamide acetaZOLAMIDE acetoHEXAMIDE amlODAROne amlLODIPine coUMADIN coVERSYL nEURONtin nOROXin valAciclovir valGANciclovir 4/19/2018 37

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