5. Medications Errors
Top 10 Medications Involved in Drug Errors
This list is based on information from the United States
Pharmacopoeia (USP), represent drug errors associated with acute
hospital care:
1. Insulin (4% of all medication errors in 2005);
2. Morphine (2.3%);
3. Potassium chloride (2.2%);
4. Albuterol (1.8%);
5. Heparin (1.7%);
6. Vancomycin (1.6%);
7. Cefazolin (1.6%);
8. Acetaminophen (1.6%);
9. Warfarin (1.4%); and
10. Furosemide (1.4%).
6. Definitions
Medication Errors
“Any preventable event that may cause or lead to inappropriat
e medication use or patient harm while the medication is in the
control of health professional, patient or consumer”
US National Co-ordinating Council for
Medication Error Reporting and Prevention
7. Definitions
‘Near miss’
An event or situation that could have resulted in
medication error, but did not, either by chance or through timel
y intervention. It is also referred to as a “close call”.
Adverse drug event
An injury resulting from drug-related interventions, e.g.
prescribing errors, dispensing errors and medication administr
ation errors.
10. Medication errors
The Institute for Safe Medication Practices (ISMP) identifies the following
areas as potential causes of medication errors:
Failed communication
Drugs with similar names
Missing or misplaced zeros and decimal points, confusion between
metric and apothecary systems of measure, use of non-standard
abbreviations (Table1), ambiguous or incomplete orders
11. Medication errors
The Institute for Safe Medication Practices (ISMP) also identifies the
following areas as potential causes of medication errors:
Poor drug distribution practices
Complex or poorly designed technology
Access to drugs by non-pharmacy personnel
Workplace environmental problems that lead to increased job stress
Dose miscalculations
Lack of patient information
Lack of patients' understanding of their therapy
22. Steps to reduce medication errors
9. Reduce ‘Hand-offs’
Starmer AJ et al; I-PASS Study Group. Changes in medical errors after implementation of a hand-off pro
gram. N Engl J Med. 2014 Nov 6;371(19):1803-12. PMID: 25372088.
Percentage of Oral Handoffs That Included Key Data Elements.
23. Steps to reduce medication errors
9. Reduce ‘Hand-offs’
Starmer AJ et al; I-PASS Study Group. Changes in medical errors after implementation of a hand-off pro
gram. N Engl J Med. 2014 Nov 6;371(19):1803-12. PMID: 25372088.
Percentage of Written Handoffs That Included Key Data Elements.
24. ‘Safer prescribing’
DO’s
• Patient info
• Standardized pre-printed
orders
• Patient education
• Protocols & Guidelines
• Indications
• How to report AE ?
DONT’s
• Using dangerous
abbreviations
• Interruptions when
prescribing medicines
35. ‘Safer administration’
DO’s
• ‘Five Rights’
• Correct dispensing directions
• Check for allergy
• Documentation & labeling
• Follow Protocol
• Infection control measures
• High-alert medicines (HAM)-
Double check
• Address caregiver or patient
queries
• How to report AE ?
DONT’s
• Dangerous abbreviations
• Interruptions when
prescribing medicines
• Outdated references
• Improper storage or
stocking
36. Improving Medication Use Process
1. Patient information (age, weight, allergies, diagnoses, and
pregnancy status);
2. Drug information (up-to-date information readily available);
3. Communication (collaborative teamwork between all healthcare
members and the patient);
4. Drug labeling, packaging, and nomenclature (limit look-alike and
sound-alike drug names, confusing packaging);
5. Drug standardization, storage, and distribution (restricting
access to high-alert drugs);
Deficiencies in any of these elements can lead to medication errors
37. Improving Medication Use Process
6. Medication delivery device acquisition, use, and monitoring;
7. Environmental factors (poor lighting, cluttered work spaces,
noise, interruptions, nonstop activity, and deficient staffing);
8. Staff competency and education;
9. Patient education; and
10. Quality processes and risk management (systems are needed
for identifying, reporting, analyzing, and reducing the risk for me
dication errors with a non-punitive culture of safety).
Deficiencies in any of these elements can lead to medication errors
38. Improving Medication Use Process
11. Improving labeling and packaging
12. Patient’s role in medication safety
Deficiencies in any of these elements can lead to medication errors
42. Reducing Risk In Specific Population
1. People with allergies
2. Paediatrics
3. Geriatrics
43. Reducing Risk In Specific Population
Key recommendations for safer use of medicines
in people with allergies include:
1. A standard protocol for the documentation of allergies.
2. Staff should be aware of their responsibilities in allergy
documentation, including updating the allergy record if a new
allergy is identified.
3. Compliance with the standard for allergy documentation to be
audited regularly.
4. All avenues used for prescribing medicines should include a
section for allergy documentation
5. Hospital in patients with documented allergies should wear
readily distinguishable wrist bands.
44. Reducing Risk In Specific Population
Key recommendations for safer use of medicines
in Pediatric population include:
1. Establish and maintain a functional pediatric formulary system wit
h policies for drug evaluation, selection and
therapeutic use.
2. All prescriptions for children should include the child’s age
and, where the dose is weight dependent the child’s weight and
the intended dose in mg/kg.
3. Dose calculations should be documented and, ideally,
double-checked before dispensing and administration.
45. Reducing Risk In Specific Population
Key recommendations for safer use of medicines
in Pediatric population include:
4. Staff should demonstrate their competence in pediatric drug
therapy including dose and infusion rate calculations
5. Infusion concentrations should be standardized to reduce errors
in calculations.
6. Infusion rate charts to aid calculation should be available for use
in pediatric units, particularly for potent drugs such as digoxin or o
piates.
7. Parents and care-givers should be taught how to handle and
administer drugs safely.
46. Reducing Risk In Specific Population
Key recommendations for safer use of medicines
in Geriatric population include:
1. Establish and maintain a functional formulary system with
policies for drug evaluation, selection and therapeutic use
specific for the elderly. All staff involved in geriatric drug
therapy should have access to the formulary.
2. Establish a structured process for reviews of patients’
medication admission to, and discharge from, hospital.
Pharmacists should be available to participate in reviews.
3. Determine which health care provider the patient is
seeing and, the medications currently prescribed.
47. Reducing Risk In Specific Population
Key recommendations for safer use of medicines
in Geriatric population include:
4. Know all of your patient's diagnoses, including
self-diagnoses that the patient may be managing with OTC or
herbal medications
5. Patient-held, shared care medication records should be
used where appropriate
6. Simplify patient’s treatment regimen.
7. Be vigilant in monitoring for adverse drug events
8. Patients and carers should be taught how to handle
and administer medicines safely
48. High Alert Medication Policy
High Alert Medications (HAM) are medications that bear a heightened
risk of causing significant patient harm when these medications are used
in error.
HAMs are based on the ISMP recommendations,
medication error reports received and feedbacks from major government
hospitals.
Though medication mishaps with HAMs may or may not be more
common than other drugs, the consequences following an error with
these drugs can be especially serious to the patient.
