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Medication Error
S. P. Bhatt M.Pharm., Ph.D.
Asst. Prof.
Dept. of Pharmacology & Clinical Pharmacy
K.B. Institute of Pharm...
Why?
• Reasons
– Medicines
– Health care
– Pharmacist as health care provider
– Objectives
Introduction
• Most of time
– Definition
– Categorization and causes of medication errors.
– Detection and prevention of m...
• Going to doctors and the pharmacist does not
always lead to cure.
• Health care delivery is not infallible. Errors are
c...
• IMPROVING MEDIACTION safety has been an
important part of the history and professional
attention of pharmacist for sever...
• As increasing in number of prescription and
over the counter medicines, number of victim
to error is increasing. It prov...
Relation between error and effect
• Relationship between medication errors and
adverse drug events.
• Bates et.al. reporte...
Time line
• For Years, medical and nursing students have
been taught Florence Nightingale's dictum—
first, do no harm. Yet...
• In 1964- Schimmel reported that 20% of
patients admitted to a university hospital
medical service suffered iatrogenic in...
• Steel et al -- 36% of patients admitted to a
university medical service in a teaching hospital
suffered an iatrogenic ev...
Eye catching and important- Results
of the Harvard Medical Practice Study
• Adverse events occurred in 3.7 percent of the ...
Some meaningful terms and its
classification.
• Individuals perceptions interpreted from
different standpoints delineate e...
What exactly is it?
• Errors in philosophical ways has been defined
as “to err is human” but all mistakes are not
under th...
Concept
• Essential terms are defines;
• Important but are not synonymous.
• Classification can helps us to make sense of
...
Medical error vs Medication error
• Hofer and colleagues address the issues of
what a medical error.
– A patient scheduled...
• Matz Robert has defined an error.
Allen EL & Barker KN
• Types of medication errors are defined, error
detection techniques are described, and the
validity ...
• But James Reason developed a well
recognized system for human error
classification based on observation from
industries ...
medication process
• Categorized into five broad stages:
– Prescription,
– Transcription,
– Preparation,
– Dispensing, and...
Reason’s model
• Causes of errors were explored.
• The model had its origin in 1987-8 during the
writing of Human Error (R...
• Reason hypothesized that most accidents can
be traced to one or more of four failure
domains: organizational influences,...
Continue….
• SCM AS A MEANS OF COMMUNICATION.
• causation.
• Other model: Mark model.
• Ishikawa diagram/ Fishbone diagram,
Defense
Latent
conditions
Active
failures
Error
producing
Conditions
Accident
Error arise for two reasons
• Active failure
– Active failures are
unsafe acts committed
by people who are in
direct conta...
Keep in Mind
• Active errors may be the dominant factor: latent conditions are
clearly important, but sometimes people rea...
Disadvantages of the Reason model
• It does not account for the detailed interrelationships among
causal factors.
• Withou...
Risk: Factors associated with increasing the likelihood of adverse health outcome
Mistake:
a knowledge based error due to ...
Lessons from psychological
and human factors research
• The subject of human error has long fascinated psychologists and o...
A THEORY OF COGNITION
• Most errors result from aberrations in mental functioning. Thus, to
understand why errors occur we...
MECHANISMS OF
COGNITIVE ERRORS
• Reason and Rasmussen classified error at each
level of
– The skill, rule and knowledge-ba...
Slips
• Skill-based activity is automatic.
• Occurs when there is a break in the routine while
attention is diverted. The ...
Types of slip
• Description error, in which the right action is
performed on the wrong object,
– such as pouring cream on ...
Factors affecting slips
• A variety of factors can divert attentional control and make slips more likely.
– Physiological ...
• Environmental factors, such as noise, heat,
visual stimuli, motion, and other physical
phenomena, also can cause distrac...
Mistake
• Rule-based errors usually occur during
problem solving when a wrong rule is
chosen—either because of a mispercep...
Mistake continue…
• Knowledge-based errors are much more complex.
The problem solver confronts a novel situation
for which...
• One such process is biased memory.
• Decisions are based on what is in our memory,
but memory is biased toward
overgener...
Mistake continue… another
mechanism
• The availability heuristic- the tendency to use
the first information that comes to ...
Factors affecting
• Rule-based and knowledge-based functioning are
affected by the same physiological, psychological, and
...
Take home question:
– Theory of error: Relation of aviation model and
medical model.
The American Society of
Hospital Pharmacists (ASHP) 1982
• a medication error as
`a dose of medication that deviates from ...
ASHP - Nine categories of medication
1. Omission error;
2. Unauthorized drug error;
3. Wrong dose error;
4. Wrong route er...
Prescribing errors
• The incorrect drug selection for patient.
• Errors in this category are fairly broad, but
generally f...
Prescription and prescribing mean?
• Prescribing is the process whereby a doctor, nurse or other
registered professional a...
• Physicians are socialized in medical school and
residency to strive for error- free practice.
• There is a powerful emph...
• Cultivating a norm of high standards is, of
course, highly desirable. It is the counterpart
of another fundamental goal ...
Prescribing error continue..
• Thirty three percent of studies reported
prescribing errors and the error prevalence
ranged...
• In 2000, Studies carried out in US hospitals
suggest that prescribing errors occur in 0.4–
1.9%.
Prescribing error – Risk factors
• Illegible hand writing
• Inaccurate history taking
• Use of abbreviation
• Inappropriat...
Error: wrong duration
• Treatment duration, therapeutic
– Cyanocobalamin12 -- 1 mg by intramuscular
injection do same (dur...
wrong drug
• Drug interaction
– Erythromycin ordered for patient taking cisapride
• Duplicative therapy:
– Atenolol ordere...
Wrong route
• Unusual/atypical drug, drug use, or route
– Tobramycin 80 mg every 8 h ordered to be given
intravenously ins...
Nomenclature
• Sound-alikes, similar dose Atrovent (ipratropium
bromide) inhaler ordered instead of Alupent
(metaprotereno...
patient
history/information/identification
– Allergy, same class Oxacillin sodium ordered for
patient with documented peni...
Factors continue
• Organizational factors like
– Attitudes of team members,
– Rate of rotation of staff absence of self hi...
• Dean B and colleague --- Most mistakes were
made because of slips in attention, or because
prescribers did not apply rel...
Transcription – error
• A specific type of data entry error that is
commonly made by human operators or by
optical charact...
Continue …
• Transcribing medication orders is when someone
transfers a physician's prescription order to a
medication adm...
• In general, transcription errors, failure to
communicate essential information, and the use of
drugs or doses inappropri...
Clear the concept
• Transposition errors are commonly mistaken for
transcription errors, but they should not be confused.
...
• Ana and colleague reported transcription
deviations, - mean of 5.37 errors per patient
(SD 4.49, 95 percent CI 5.05-5.69...
Transcription errors
• Continuing a GP’s prescribing error when writing a patient’s drug
chart on admission to hospital.
•...
Dispensing error.
• Dispensing error occur at any stage of the
dispensing process, from the receipt of the
prescription to...
Receiving
prescription
Container
selection and
labeling
Reading and
refusal
Cross check
Compounding
Drug selection
Deliver...
Classification of dispensing errors
Incorrect drug Dispensing a drug that is different to that prescribed. Excludes generic...
Missing doses Missing doses Dispensing a smaller quantity of medication to that
prescribed.
Omission of
item
Omission of i...
Communication failure  ambiguous, incomplete or confusing prescription, illegible writing and
unreadibility, typographic ...
Communication failure
• The prescription is responsible fore conveying
information about prescribed drug and its
usage in ...
• Manual writing may complicate the distinction
between two drugs with similar names.
• Many drugs have similar names or d...
Writing
• Capital E and F
• 1 and L
• L and I
• U and micro
• C and e
Problem related to drug labeling and
packaging
• Problems related to drug labeling and packaging are the second
most repor...
Working environment
• Pharmacist can be affected by their work
environment in which that can increase or
decrease the rate...
Sociotechnical areas
• Four sociotechnical areas are applied to
community practice there are believed to
influence cogniti...
Continue..
• Previous studies from community practice
describe errors in
– work flow,
– satisfaction,
– safety,
– lightnin...
India ????
• Mass merchants and supermarkets typically
offer one stop shopping for medicaments,
groceries and other genera...
Lighting
• Light is critical to human functioning.
• It allows us to see things and perform activities.
• Improper illumin...
Noise
• Certain types of noise and sounds have been
found to reduce the occurrence of dispensing
error. Unpredictable soun...
Workload
• No of persons
– LESS or no skilled person/staff
– Too much prescription load
– Time of the day
– Not usual disp...
?
• Practice makes man perfect then
– Do busy pharmacist make mistakes?
– Many studies have assessed relationship between
...
Drug information
• The latest advents in technological and
pharmaceutical sectors led to frequent changes in
information r...
NCC MERP
• The National Coordinating Council for
Medication Error Reporting and Prevention
(NCC MERP) is an independent bo...
Vision
• No patient will be harmed by a medication
error.
Mission
• To maximize the safe use of medications and
to increase awareness of medication errors
through open communicatio...
What is a Medication Error?
– "A medication error is any preventable event that may
cwhile the medication is in the contro...
Medication Error Index
• Medication Error Index classifies an error
according to the severity of the outcome,
NCC MERP Index for Categorizing Medication
Errors Algorithm
Take home questions
• Recommendations to Enhance Accuracy of
Prescription Writing.
• Prepare the list of dangerous abbrevi...
Error producing
condition
Work environment Physical environment
Heavy Workload
New or local staff
Staffing
Inadequate
Enga...
Administration error
• The administration of a medicine is a common
but important clinical procedure.
• It is the manner i...
• Because nurses are directly and consistently
involved in the administration phase of the
medication process, they experi...
literature on errors specific to drug
administration--voluminous
• 400 people die or are seriously injured in
adverse even...
• It is clear from the literature on errors specific
to drug administration that there is further
room for improvement.
Recall and add
• Allen & Barker (1990) use terminology which
is almost identical to Cooper (1995) who
suggest an error is:...
Barker & McConnell --1962
– ‘The administration of the wrong medication,
drug, diagnostic agent, chemical or treatment
req...
• Barker and McConnell’s definition can, however,
include such related procedures as incorrect
handwashing (hand washing t...
Nurse - administration
• Mathematical skills of nurses
• Length of nursing experience
• Knowledge of medications
• Length ...
Self - administration
• Knowledge
• Skill
• Personal-individual factors
• Environmental factors
Nurse - administration
• Mathematical skills of nurses
– Poor mathematical skills in individual nurses can
contribute to i...
Continue…
• Nurses actually make conceptual errors
related to a particular problem, i.e. they fail to
construct a logical ...
Knowledge
• Nurse’s knowledge should be sufficient to afford
competence in the administration of drugs.
• The variables th...
• Nurses with more educational qualifications
held a better knowledge of medications.
• Kawamura: In a Japanese study of 2...
Length of nursing experience
• Practice makes man perfect. If so
• are errors being made by experienced staff as
opposed t...
• Nurses new to either the job or the hospital in
which they work are more likely to make
errors but are also more likely ...
• Staff moving from one clinical area to another
may also be susceptible unless they have
moved to a very similar setting....
Length of nursing rosters
• Type of roster – days,
nights, or twilight shifts
can contribute towards
raising the risk of e...
More medication errors can occur
during the day??? Simply-logically
• Increased number of prescriptions issued and
altered...
Workload, staffing levels and delivery
systems
• Important and a sensitive factor.
• The politico-legal, and economic rami...
Conclusion from Roseman and Booker
• Assessed the effects of a range of workload
factors.
• They found errors increased in...
• Taunton et al (1994) claim, as a result of
studying patient outcomes – inclusive of drug
error, that there is no relatio...
Single nurse administration
• Single nurse administration does not
necessarily increase the number of errors.
• If the var...
• Jeanes & Taylor in 1992 reported that single
nurse administration does not necessarily
increase the number of errors.
• ...
Policy and procedure
• Absence
• Existence
• Poor interpretation
• Many drug errors arise as a result of failure to
follow...
Distraction and interruptions
• Errors is also dependent upon the nature of the
clinical setting.
• Drugs are often admini...
Quality of prescriptions
• Failures in communication can sometimes relate
directly to poorly written prescriptions.
• Farr...
Methodologies used to study
medication errors
• Direct observation method
– With some confirming the error once the medica...
• Prospective methods
– errors through routine activity or chart review
– Interview and blend of all
– directly observing ...
• Self-report data
Methodologies used to study
medication errors
• Prospective chart review
• Direct observation
• Error reports
• Focus grou...
• informal and formal
interviews
• Structured interview
• Semi-structured
interviews and coding
• Prospective procedure
re...
• Staff interviewed by a researcher using both
closed- and open-ended questions to
determine contributory events and condi...
Drugs Commonly Associated with Medication Errors
DRUG TYPE EXAMPLES OF COMMON ERRORS
Analgesics Over sedation, over dose, ...
Examples of Situations Requiring Hypervigilance to Avoid
Medication Error
• Inadequate patient information
– Clinical team...
• Drug require manipulation
– Inaccurate dosing when splitting, crushing, or
suspending a medication
• Drug dosing require...
• Children
– Wrong dose, route, or frequency
– Calculation of drug dose depending on weight
– Administration of medication...
How to prevent
• Recommendations for Preventing Medication
Errors.
– Organizational and Departmental
– Prescribers
– Pharm...
Organizational and Departmental
• Organizational policies and procedures should
be established to prevent medication error...
• The formulary system, the P&T committee should be responsible for formulating
policies regarding the evaluation, selecti...
• Responsible staff for processing drug orders should have routine access to
appropriate clinical information about patien...
• Except in emergency situations, all sterile and nonsterile drug products should be
dispensed from the pharmacy departmen...
• Where possible, the use of technological innovations such as bar coding is
recommended.
• Adequate drug information reso...
Recommendations for Prescribers.
• To determine appropriate drug therapy, prescribers should stay abreast of the
current s...
• Care should be taken to ensure that the intent of medication
orders is clear and unambiguous.
• Write out instructions r...
• Written drug or prescription orders (including signatures) should be
legible. Prescribers with poor handwriting should p...
Recommendations for Pharmacists
• Participate in drug therapy monitoring
• Stay abreast of the current state of knowledge
...
• Review the use of auxiliary labels
• Ensure that medications are delivered to the patient-care
area in a timely fashion ...
• Electronic prescribing may help to reduce the
risk of prescribing errors resulting from
illegible hand writing.
• Comput...
Recommendations for Nurses
• Familiar with the medication ordering and use
System
• Review patients’ medications with resp...
• Verify multiple drug entry and prescription
• Understand and explain use, care and caution on
the use of devises use in....
Patients and Personal Caregivers.
• Inform and communicate
• Feel free to ask question
• Learn medicine and use.
• Adhere ...
Pharmaceutical Manufacturers and
approving authority
• Involve pharmacists, nurses, and physicians in
decisions about drug...
• Special instructions should be highlighted on
labeling.
• The most prominent items on the product
label should be inform...
Use of technology to minimise error
• Health information technologies
– electronic prescribing,
– electronic health record...
Information technology Benefits Barrier
Computerized or
electronic medical
record
Provides patient information
to guide dr...
Take home question
• Automated prospective drug utilization review
systems?
• Electronic medication administration and
rec...
Information technology Benefits Barrier
Automated dispensing
devices (ADD)/
AD unit
Holds medications at a
specific locati...
Information technology Benefits Barrier
Physical packaging
changes
Changes appearance of
medications to avoid errors
assoc...
Information
technology
Benefits Barrier
Bar coding Automated record of medication
administration to specific patients
Chec...
Cases and Example
Photograph showing almost similar looking ampoules of Inj. Ondoc-2 (Ondansetron) and Inj. Tramadoc
(Tramadol Hydrochloride...
HOW SIMILAR IS TOO SIMILAR/EXACT
• Visiting a website for same is easy but working
on the same to keep record and put it in
practice may difficult.
• Flood...
• A patient was administered 80 units of insulin
instead of the prescribed 8 units.
• The patient required emergency treat...
• A newly qualified staff nurse on a hospital
ward administered a Medication Dobutamine
to a patient via a IVF when it was...
• A 78 year old man with human immunodeficiency virus (HIV)
accessed our hospital and was brought to our attention in Augu...
• A Pittsburgh pharmacist mistranscribes a
telephone Rx, which calls for two 0.25-mcg
Rocaltrol pills four times per day. ...
• A Florida R.Ph. dispenses Cycrin, a female
hormone, instead of the Coumadin
prescribed. The patient takes the wrong drug...
• An South Carolina pharmacist dispenses
Glynase 6 mg instead of the Ritalin precribed.
The patient, a seven-year-old girl...
Disclosure of error
• There are few research work has been
reported in literature about the error.
• We have to think how ...
• Disclosure will be continue….
Questions?
Medication error
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Medication error

  1. 1. Medication Error S. P. Bhatt M.Pharm., Ph.D. Asst. Prof. Dept. of Pharmacology & Clinical Pharmacy K.B. Institute of Pharm. Edu. & Res. Gandhinagar, Gujarat.
  2. 2. Why? • Reasons – Medicines – Health care – Pharmacist as health care provider – Objectives
  3. 3. Introduction • Most of time – Definition – Categorization and causes of medication errors. – Detection and prevention of medication errors. – Role of pharmacist.
  4. 4. • Going to doctors and the pharmacist does not always lead to cure. • Health care delivery is not infallible. Errors are common in most health care systems. • Medicines are effective but side effects are free. – side-effect – adverse reaction – error – adverse event
  5. 5. • IMPROVING MEDIACTION safety has been an important part of the history and professional attention of pharmacist for several decades even though this has been a topic of public interest only recently. • Research by the pharmacist as long as related to work in patient safety.
  6. 6. • As increasing in number of prescription and over the counter medicines, number of victim to error is increasing. It proves still Errors are inevitable. • It is reported to be the seventh most cause of death of overall.
  7. 7. Relation between error and effect • Relationship between medication errors and adverse drug events. • Bates et.al. reported the frequency of medication errors using a multidisciplinary approach, to classify these errors by type, and to determine how often medication errors are associated with adverse drug events (ADEs) and potential ADEs. Bates DW et. Al. Relationship between medication errors and adverse drug events. J Gen Intern Med. 1995;10(4):199-205.
  8. 8. Time line • For Years, medical and nursing students have been taught Florence Nightingale's dictum— first, do no harm. Yet evidence from a number of sources, reported over several decades, indicates that a substantial number of patients suffer treatment-caused injuries while in the hospital • Research related to medication use safety began to be published in the literature decades ago.
  9. 9. • In 1964- Schimmel reported that 20% of patients admitted to a university hospital medical service suffered iatrogenic injury and that 20% of those injuries were serious or fatal. • Recent medical progress has brought dramatic advances in methods of diagnosis and treatment. With each new advance, however, reports of adverse reactions have soon followed. The occurrence of occasional reactions is now considered to be an accustomed and almost predictable hazard rather than evidence of improper medical care Schimmel EM. The Hazards of Hospitalization Ann Intern Med. 1964;60(1):100-110.
  10. 10. • Steel et al -- 36% of patients admitted to a university medical service in a teaching hospital suffered an iatrogenic event, of which 25% were serious or life threatening. More than half of the injuries were related to use of medication. • In 1991 Bedell et al reported the results of an analysis of cardiac arrests at a teaching hospital. They found that 64% were preventable. Again, inappropriate use of drugs was the leading cause.
  11. 11. Eye catching and important- Results of the Harvard Medical Practice Study • Adverse events occurred in 3.7 percent of the hospitalizations . • 27.6 percent of the adverse events were due to negligence Although 70.5 percent of the adverse events gave rise to disability lasting less than six months, • 2.6 percent caused permanently disabling injuries and percent led to death. • The percentage of adverse events attributable to negligence increased in the categories of more severe injuries (Wald test χ2 = 21.04, P<0.0001). • Using weighted totals, we estimated that among the 2,671,863 patients discharged from New York hospitals in 1984 there were 98,609 adverse events and 27,179 adverse events involving negligence. • Rates of adverse events rose with age (P<0.0001). The percentage of adverse events due to negligence was markedly higher among the elderly (P<0.01).
  12. 12. Some meaningful terms and its classification. • Individuals perceptions interpreted from different standpoints delineate errors. • Patients, professionals, managers and health policy makers will ascribe different meaning to events. • Therefore, it is necessary to understand some meaningful terms and its classification.
  13. 13. What exactly is it? • Errors in philosophical ways has been defined as “to err is human” but all mistakes are not under the same heading. • Synthesizing and interpreting the findings in literature pertaining to error in health care is complicated due to absence of standardized nomenclature.
  14. 14. Concept • Essential terms are defines; • Important but are not synonymous. • Classification can helps us to make sense of world, helps to understand, and assesses error. • Numerous attempts to develop classification of error. But one of the problems with classifying error is that there are so many ways of doing
  15. 15. Medical error vs Medication error • Hofer and colleagues address the issues of what a medical error. – A patient scheduled for an amputation of the right leg has the left leg removed. – A patient is discharged from the hospital after myocardial infarction without having a b-blocker prescribed.
  16. 16. • Matz Robert has defined an error.
  17. 17. Allen EL & Barker KN • Types of medication errors are defined, error detection techniques are described, and the validity of several medication error studies is evaluated. • A medication error is generally defined as: “a deviation from the physician's medication order as written on the patient's chart. In hospitals, medication errors occur at a rate of about one per patient per day” Allan EL. Barker KN. Fundamentals of medication error research. Am J Hosp Pharm. 1990;47(3):555-71.
  18. 18. • But James Reason developed a well recognized system for human error classification based on observation from industries that have become reliable.
  19. 19. medication process • Categorized into five broad stages: – Prescription, – Transcription, – Preparation, – Dispensing, and – Administration
  20. 20. Reason’s model • Causes of errors were explored. • The model had its origin in 1987-8 during the writing of Human Error (Reason 1990). – The original intention for the book was to provide an essentially cognitive psychological account of the nature, varieties, and the mental sources of human error. • A model used in risk analysis and risk management, including aviation, engineering and healthcare. It likens human systems to multiple slices of swiss cheese, stacked side by side. • Propounded by Dante Orlandella and James T. Reason of the University of Manchester, and has since gained widespread acceptance.
  21. 21. • Reason hypothesized that most accidents can be traced to one or more of four failure domains: organizational influences, supervision, preconditions and specific acts. Preconditions for unsafe acts include fatigued air crew or improper communications practices.
  22. 22. Continue…. • SCM AS A MEANS OF COMMUNICATION. • causation. • Other model: Mark model. • Ishikawa diagram/ Fishbone diagram,
  23. 23. Defense Latent conditions Active failures Error producing Conditions Accident
  24. 24. Error arise for two reasons • Active failure – Active failures are unsafe acts committed by people who are in direct contact with the patient. – They take a variety of form as given in BOX:1 • Latent condition. – Latent conditions are resident pathogens within the system. – They can affect the rate at which employees execute active failure and its associated risk
  25. 25. Keep in Mind • Active errors may be the dominant factor: latent conditions are clearly important, but sometimes people really just slip up, • The causal link, or even the connection, between distant latent conditions and accidents are often tenuous, and only visible with the benefit of hindsight, • Latent conditions can always be identified, with or without an accident, • Some latent conditions may be very difficult to control, or take many years to address, • Misapplication of the model can shift the blame backwards, from a ‘blame the pilot’ to ‘blame the management’ culture, • Highlighting management problems may hide very real human factors issues, like the impact of emotion on performance, and hamper the research needed to better understand human fallibility.
  26. 26. Disadvantages of the Reason model • It does not account for the detailed interrelationships among causal factors. • Without these distinct linkages, the results are too vague to be of significant practical use. • Model is insufficiently specific regarding the nature of the holes in the cheese and their inter-relationships.
  27. 27. Risk: Factors associated with increasing the likelihood of adverse health outcome Mistake: a knowledge based error due to an incorrect thought process or analysis Lapse: a failure to execute an action due to a routine behaviour being misdirected Negligence Negligent adverse events represent a subset of preventable adverse events that satisfy legal criteria used in determining negligence. Active error: Failure at the level of the frontline operator Latent error: Failure that tend to be removed from the direct control of the operator and include things like poor design, mistake in maintenance and bad decisions. Error The failure, for reason which are preventable, of a planned action to be completed as intended or use of wrong plan to achieve aim Adverse drug event: Any injury related to the use of a drug Error of Omission: Failure to perform an appropriate action Error of Commission: Performing an inappropriate action
  28. 28. Lessons from psychological and human factors research • The subject of human error has long fascinated psychologists and others, but both the development of theory and the pace of empirical research accelerated in response to the dramatic technological advances that occurred during and after World War II. • These theory development and research activities followed two parallel and intersecting paths: – human factors research and cognitive psychology.
  29. 29. A THEORY OF COGNITION • Most errors result from aberrations in mental functioning. Thus, to understand why errors occur we must first understand normal cognition. • Reason captures the main themes of cognitive theory and is consistent with empirical observation. • "schematic control mode“ – definite process. • Rasmussen and Jensen describe a model of performance based on concept of cognition that is particularly well suited for error analysis. • They classify human performance into three levels: – (1) skill-based, which is patterns of thought and action that are governed by stored patterns of preprogrammed instructions (schemata) and largely unconscious; – (2) rule-based, in which solutions to familiar problems are governed by stored rules of the "if X, then Y“ variety; and – (3) knowledge-based, or synthetic thought, which is used for novel situations requiring conscious analytic knowledge.
  30. 30. MECHANISMS OF COGNITIVE ERRORS • Reason and Rasmussen classified error at each level of – The skill, rule and knowledge-based model. • Skill-based errors are called "slips." – These are unconscious glitches in automatic activity. – Slips are errors of action. • Rule based and knowledge based errors, by contrast, are errors of conscious thought and are termed "mistakes." • The mechanisms of error vary with the level.
  31. 31. Slips • Skill-based activity is automatic. • Occurs when there is a break in the routine while attention is diverted. The actor possesses the requisite routines; errors occur because of a lack of a timely attentional check. • In brief, slips are monitoring failures. They are unintended acts. • A common mechanism of a slip is capture, in which a more frequently used schema takes over from a similar but less familiar.
  32. 32. Types of slip • Description error, in which the right action is performed on the wrong object, – such as pouring cream on a pancake. • Associative activation errors result from mental associations of ideas, such as answering the phone when the doorbell rings. • Loss of activation errors are temporary memory losses, such as entering a room and no longer remembering why you wanted to go there. Loss of activation errors are frequently caused by interruptions.
  33. 33. Factors affecting slips • A variety of factors can divert attentional control and make slips more likely. – Physiological factors • include fatigue, sleep loss, alcohol, drugs, and illness. Psycho¬ – psychological factors include other activity ("busyness"), as well as emotional states • such as boredom, frustration, fear, anxiety, or anger. • All these factors lead to preoccupations that divert attention. • Psychological factors, though considered "internal" orendogenous, may also be caused by a host of – External Factors, • such as overwork, interpersonal relations, and many other forms of stress. – Environmental factors, such as noise, heat, visual stimuli, motion, and – other physical phenomena, also can cause distractions that divert attention and lead to slips.
  34. 34. • Environmental factors, such as noise, heat, visual stimuli, motion, and other physical phenomena, also can cause distractions that divert attention and lead to slips.
  35. 35. Mistake • Rule-based errors usually occur during problem solving when a wrong rule is chosen—either because of a misperception of the situation and thus, the application of a wrong rule or because of misapplication of a rule, usually one that is strong (frequently used), that seems to fit adequately. • Errors result from misapplied expertise.
  36. 36. Mistake continue… • Knowledge-based errors are much more complex. The problem solver confronts a novel situation for which he or she possesses no preprogrammed solutions. • Errors arise because of lack of knowledge or misinterpretation of the problem. Pattern matching is preferred to calculation, but sometimes we match the wrong patterns. • Certain habits of thought have been identified that alter pattern.
  37. 37. • One such process is biased memory. • Decisions are based on what is in our memory, but memory is biased toward overgeneralization and over regularization of the commonplace. • Familiar patterns are assumed to have universal applicability because they usually work. We see what we know. • Paradoxically, memory is also biased toward overemphasis on the discrepant. A
  38. 38. Mistake continue… another mechanism • The availability heuristic- the tendency to use the first information that comes to mind. • Related are confirmation bias- the tendency to look for evidence that supports an early working hypothesis and to ignore data that contradict it, • Overconfidence- the tendency to believe in the validity of the chosen course of action and to focus on evidence that favors it.
  39. 39. Factors affecting • Rule-based and knowledge-based functioning are affected by the same physiological, psychological, and environmental influences that produce slips. • stress: not a bad, at certain level improves performance. It has long been known that "a little anxiety improves performance. • In 1908, Yerkes and Dodson showed that performance is best at moderate levels of arousal. • Poor performance occurs at both extremes: boredom and panic. • Coning of attention under stress is the tendency in an emergency to concentrate on one single source of information, the "first come, best preffred.
  40. 40. Take home question: – Theory of error: Relation of aviation model and medical model.
  41. 41. The American Society of Hospital Pharmacists (ASHP) 1982 • a medication error as `a dose of medication that deviates from the physician's order as written in the patient's chart or from standard hospital policy and procedures'
  42. 42. ASHP - Nine categories of medication 1. Omission error; 2. Unauthorized drug error; 3. Wrong dose error; 4. Wrong route error; 5. Wrong rate error; 6. Wrong dosage form error; 7. Wrong time error; 8. Wrong preparation of a dose; 9. Incorrect administration technique.
  43. 43. Prescribing errors • The incorrect drug selection for patient. • Errors in this category are fairly broad, but generally focus on inappropriate drug selection, dose, dosage form selection, or route of administration, and prescribing of contraindicated drugs. • Lack of knowledge of the prescribed drug, its recommended dose and the patient information leads to prescribing error.
  44. 44. Prescription and prescribing mean? • Prescribing is the process whereby a doctor, nurse or other registered professional authorises use of medications or treatments for a patient and provides instructions about how and when those treatments should be used. • Although the term commonly refers to orders for medicines, the concept can equally encompass laboratory tests, medical imaging, psychological treatments, eye glasses, eating and exercise regimes or other instructions to help optimise health and wellbeing
  45. 45. • Physicians are socialized in medical school and residency to strive for error- free practice. • There is a powerful emphasis on perfection, both in diagnosis and treatment. • In everyday hospital practice, the message is equally clear: mistakes are unacceptable. • Physicians are expected to function without error, • An expectation that physicians translate into the need to be infallible.
  46. 46. • Cultivating a norm of high standards is, of course, highly desirable. It is the counterpart of another fundamental goal of education: developing the physician's sense of responsibility for the patient. – If you are responsible for everything that happens to the patient, it follows that you are responsible for any errors that occur. – Physicians do not have the power to control all aspects of patient.
  47. 47. Prescribing error continue.. • Thirty three percent of studies reported prescribing errors and the error prevalence ranged from 29.8% to 47.8% in different studies. • Prescribing errors varied in different studies depending on their units of observations; 38.4% to 47.8% in medical Charts, 29.8% to 37.2% in patients, and 35.1% in administered doses.
  48. 48. • In 2000, Studies carried out in US hospitals suggest that prescribing errors occur in 0.4– 1.9%.
  49. 49. Prescribing error – Risk factors • Illegible hand writing • Inaccurate history taking • Use of abbreviation • Inappropriate information in haphazard writing pattern. • Work load. • Level of seniority and experience. • Ward/medicine specialty. • COMMUNICATION, • Working environment, • Physical and mental well being, and • Lack of knowledge are identified.
  50. 50. Error: wrong duration • Treatment duration, therapeutic – Cyanocobalamin12 -- 1 mg by intramuscular injection do same (duration not limited) • Treatment duration, toxicity – Digoxin 0.5 mg intravenously, then 0.25 mg intravenously every 4 h (duration not limited)
  51. 51. wrong drug • Drug interaction – Erythromycin ordered for patient taking cisapride • Duplicative therapy: – Atenolol ordered for patient taking metoprolol • No indication: – Vancomycin hydrochloride ordered for patient with Enterobacter infection – Inj amikacine ordered for patient with UTI. • Combination products – Propoxyphene napsylate and aspirin instead of propoxyphene napsylate with acetaminophen • Wrong drug, same class: – Clarithromycin 500 mg once, then 250 mg for 4 d instead of Azithromycin • Wrong drug, linked therapies: – Potassium 40 mEq intravenously instead of Furosemide 40 mg intravenously • Contraindications: – Timolol maléate eye drops for patient with severe asthma
  52. 52. Wrong route • Unusual/atypical drug, drug use, or route – Tobramycin 80 mg every 8 h ordered to be given intravenously instead of by nebulization – Abbreviations Bisacodyl ordered "PT" (per tube) instead of "PR" (per rectum) – Dosage form Betamethasone sodium phosphate/acetate suspension ordered to be given intravenously • Wrong dosage form – Aqueous penicillin 1.2 million units by intramuscular Injection ordered for pharyngitis
  53. 53. Nomenclature • Sound-alikes, similar dose Atrovent (ipratropium bromide) inhaler ordered instead of Alupent (metaproterenol sulfate) • Sound-alikes, dissimilar dose Dicloxacillin 100 mg instead of • doxycycline 100 mg • Failure to specify dosage form Theophylline 800 mg daily without specifying sustained-release form • Brand name lacking suffix/prefix.
  54. 54. patient history/information/identification – Allergy, same class Oxacillin sodium ordered for patient with documented penicillin allergy – Allergy, related class Ibuprofen ordered for patient with documented aspirin allergy – Wrong patient Antibiotics ordered in wrong patient's chart.
  55. 55. Factors continue • Organizational factors like – Attitudes of team members, – Rate of rotation of staff absence of self hierarchical positions, and absence of self awareness about prescribing error may contribute12-15. – Moreover, physicians’ do not routinely screen drug- drug interactions. – In an analysis of 424 randomly selected visitors of hospital emergency department, 47% led to added medication and in 10% of the visits in which at least one medication was added. • Beers MH, Storrie m, Lee G. Potential adverse drug interactions in the emergency room. Ann Intern Med 1990;112(1):61-64.
  56. 56. • Dean B and colleague --- Most mistakes were made because of slips in attention, or because prescribers did not apply relevant rules. • Doctors identified many risk factors- – work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. • Organisational factors were also identified, and included – Inadequate training, low perceived importance of prescribing, a hierarchical medical team, and an absence of self-awareness of errors. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 2002;359(9315):1373-8
  57. 57. Transcription – error • A specific type of data entry error that is commonly made by human operators or by optical character recognition programs (OCR). • Human transcription errors are commonly the result of typographical mistakes, putting fingers in the wrong place during touch typing is the easiest way to ascertain this error.
  58. 58. Continue … • Transcribing medication orders is when someone transfers a physician's prescription order to a medication administration record. • The transcription of the prescription is the second most important step in the medication process because any minor error could lead to trouble for the patient taking the medicine. Transcription always receives heavy scrutiny.
  59. 59. • In general, transcription errors, failure to communicate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors;
  60. 60. Clear the concept • Transposition errors are commonly mistaken for transcription errors, but they should not be confused. • Transposition errors occur when characters have “transposed”—that is, they have switched places. • Transposition errors are almost always human in origin. • The most common way for characters to be transposed is when a user is touch typing at a speed that makes them input one character, before the other. • This may be caused by their brain being one step ahead of their body.
  61. 61. • Ana and colleague reported transcription deviations, - mean of 5.37 errors per patient (SD 4.49, 95 percent CI 5.05-5.69). • In absolute terms, there were 4,067 transcription errors out of a possible 33,468 (12.15 percent, 95 percent CI 11.80-12.50).
  62. 62. Transcription errors • Continuing a GP’s prescribing error when writing a patient’s drug chart on admission to hospital. • Transcribing a medication order incorrectly when rewriting a patient’s drug chart. • Writing “milligrams” when “micrograms” was intended. • Writing a prescription for discharge medication that unintentionally deviates from the medication prescribed on the inpatient drug chart. • On admission to hospital, writing a medication order that unintentionally deviates from the patient’s pre-admission prescription.
  63. 63. Dispensing error. • Dispensing error occur at any stage of the dispensing process, from the receipt of the prescription to the delivery of the prescription. • It can also be defined as “dispensed and filled prescription that contains one or more deviation from the prescriber’s written order.
  64. 64. Receiving prescription Container selection and labeling Reading and refusal Cross check Compounding Drug selection Delivery Error in dispensing
  65. 65. Classification of dispensing errors Incorrect drug Dispensing a drug that is different to that prescribed. Excludes generic or therapeutic substitution authorised by written hospital policy. incorrect strength incorrect strength Dispensing a dose unit containing the wrong amount of the correct drug, without an appropriate adjustment to the dosing instructions Incorrect dosage form Incorrect dosage form Dispensing the correct drug in a dosage form different to that prescribed. This includes supplying a modified release formulation when a standard formulation was prescribed. Dose added Dose added Dispensing a larger quantity of medication to that prescribed. Missing doses Missing doses Dispensing a smaller quantity of medication to that prescribed.
  66. 66. Missing doses Missing doses Dispensing a smaller quantity of medication to that prescribed. Omission of item Omission of item Failure to dispense a prescribed item. Other content error Other content error Any other content error not included in the above categories. Deteriorated medication Dispensing a medication that has exceeded its expiry date or has been stored at a temperature different to that required, or for which the primary packaging is damaged. Other content error Any other content error not included in the above categories. Documentation and mechanical error.
  67. 67. Communication failure  ambiguous, incomplete or confusing prescription, illegible writing and unreadibility, typographic and phonetic similarity in name Problem in labeling and packaging  similar label and packages in size, shape and color Working environment  inadequate space poor lighting noise high temperature  interruption and distraction work overload  inadequate space to store drugs  little time on individual prescription handling Drug information  lack of health care professionals and physicians information about medicine Absence of protocol and sops, negligence of management, low morals, unfamiliar tasks, unawareness of risk factors and design of pharmacy.
  68. 68. Communication failure • The prescription is responsible fore conveying information about prescribed drug and its usage in a way that any one reading it may fully understand the instructions. • Ambiguous, incomplete or confusing prescription may lead to poor understanding of fundamental information for correct drug dispensing and delivery of prescription. • Prescription readability problems are well known as a cause of medication errors.
  69. 69. • Manual writing may complicate the distinction between two drugs with similar names. • Many drugs have similar names or drug names may sound and pronounce similar that lead to confusion particularly when they are delivered through same route of administration. • “Livoxin (Levofloxacine)” and “Lanoxin (Digoxin)” are examples of names which when written or readout look similar • Further emphasis need to prescribe with generic name. • Similar drug names are responsible for one third of medication error reported in the United States
  70. 70. Writing • Capital E and F • 1 and L • L and I • U and micro • C and e
  71. 71. Problem related to drug labeling and packaging • Problems related to drug labeling and packaging are the second most reported category in the most frequent medication error reported in the USPMERP ad are responsible about 20% of notification. • Wrong on label – Drug/form on label – Strength – Direction – Patient name – Container – Quality and information – Selection error related to above all – Bagging error : wrong name on bag, address, item omitted, extra items added Critical in life saving drugs
  72. 72. Working environment • Pharmacist can be affected by their work environment in which that can increase or decrease the rate of dispensing error. • Pharmacist performs tasks that are at times somewhat repetitive, yet require high level of professional training and optimal performance under considerable time constrain.
  73. 73. Sociotechnical areas • Four sociotechnical areas are applied to community practice there are believed to influence cognitive functions when processing prescriptions.
  74. 74. Continue.. • Previous studies from community practice describe errors in – work flow, – satisfaction, – safety, – lightning, – noise, – workload – interruption and distraction.
  75. 75. India ???? • Mass merchants and supermarkets typically offer one stop shopping for medicaments, groceries and other generalized medicines. While independently owned pharmacies are smaller store offering specialty items and services in health care.
  76. 76. Lighting • Light is critical to human functioning. • It allows us to see things and perform activities. • Improper illumination affects activities and tends to error. • Buchanan and colleagues studied the effects of lightening level on dispensing error in a high volume army out patient pharmacy. • They found out that error rate were reduced when work surface level were high.
  77. 77. Noise • Certain types of noise and sounds have been found to reduce the occurrence of dispensing error. Unpredictable sounds, controllable sounds and noise had a lower dispensing error. • Distractions: – Telephone interruption – Staff/visitors/chatting with neighbor and address query – Customer/patient query – Busy over-the-counter trade – Other distraction – blow horn, transport, cherr up
  78. 78. Workload • No of persons – LESS or no skilled person/staff – Too much prescription load – Time of the day – Not usual dispenser – Poor relationship with overall job dissatisfaction perception – Inadequate breaks between work periods. – System design, • Busyness – Time and seasons – Other trading
  79. 79. ? • Practice makes man perfect then – Do busy pharmacist make mistakes? – Many studies have assessed relationship between prescription workload and dispensing errors.
  80. 80. Drug information • The latest advents in technological and pharmaceutical sectors led to frequent changes in information relating to drug use and safety. • It is a dangerous practice to use traditional or virtual book, out dated information sources, websites and other unreliable material to surpass the information. Pharmacist must keep abreast with latest in the field of medicine from the reliable and convenient sources of information. • Updating the information will help to maintain professional rapport as well helpful in patient counseling.
  81. 81. NCC MERP • The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is an independent body comprised of 27 national organizations. • In 1995, USP spearheaded the formation of the National Coordinating Council for Medication Error Reporting and Prevention
  82. 82. Vision • No patient will be harmed by a medication error.
  83. 83. Mission • To maximize the safe use of medications and to increase awareness of medication errors through open communication, increased reporting and promotion of medication error prevention strategies.
  84. 84. What is a Medication Error? – "A medication error is any preventable event that may cwhile the medication is in the control of the health care ause or lead to inappropriate medication use or patient harm 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."
  85. 85. Medication Error Index • Medication Error Index classifies an error according to the severity of the outcome,
  86. 86. NCC MERP Index for Categorizing Medication Errors Algorithm
  87. 87. Take home questions • Recommendations to Enhance Accuracy of Prescription Writing. • Prepare the list of dangerous abbreviations. • Councils recommendations – cover in how to prevent
  88. 88. Error producing condition Work environment Physical environment Heavy Workload New or local staff Staffing Inadequate Engage with some other activityTeam members Communication Supervision Responsibility Individual Physical health, fatigue, psychology, stress Low moral Skill and knowledge Training Knowledge Calculation Task No professional/routine Protocol Patient Unhelpful Complex clinical diseases Language and communication gap Out side – inside
  89. 89. Administration error • The administration of a medicine is a common but important clinical procedure. • It is the manner in which a medicine is administered that will determine to some extent whether or not the patient gains any clinical benefit, and whether they suffer any adverse effect from their medicines. • The medication process is complex and involves a number of different individuals and disciplines, thereby increasing the risk of error.
  90. 90. • Because nurses are directly and consistently involved in the administration phase of the medication process, they experience the distress of potentially committing an error. • Since nurses are intimately involved in the delivery of medications and are ultimately responsible during the medication administration phase, it is important not only for nursing but also all health care providers to understand factors contributing to medication administration errors and factors leading to the discovery of potential medication administration errors.
  91. 91. literature on errors specific to drug administration--voluminous • 400 people die or are seriously injured in adverse events involving medical devices; • nearly 28 000 written complaints are made about aspects of clinical treatment in hospitals; • the NHS pays out approximately 400 million a year in settlement of clinical negligence claims;
  92. 92. • It is clear from the literature on errors specific to drug administration that there is further room for improvement.
  93. 93. Recall and add • Allen & Barker (1990) use terminology which is almost identical to Cooper (1995) who suggest an error is: – ‘A dose of medication that deviates from the physician’s medication order on the patients chart.’ (Cooper 1995, p. 488).
  94. 94. Barker & McConnell --1962 – ‘The administration of the wrong medication, drug, diagnostic agent, chemical or treatment requiring the use of such agents, to the wrong patient or at the wrong time or failure to administer such agents at the specified time or in the manner prescribed or normally considered as accepted practice.’ Barker & McConnell (1962) in their commonly cited study is more detailed and wide ranging but also lacks specific reference to incorrect prescribing:
  95. 95. • Barker and McConnell’s definition can, however, include such related procedures as incorrect handwashing (hand washing that is not in accordance with local practice) prior to giving an intravenous medication. • Bates (1996), it is argued that in organizations outside the health care sector, the most common cause of errors is the production process or system rather than the individuals working within it.
  96. 96. Nurse - administration • Mathematical skills of nurses • Length of nursing experience • Knowledge of medications • Length of nursing rosters • Workload, staffing levels and delivery systems • Single vs multiple number of nurse administration. • Policy and procedure • Distraction and interruptions • Quality of prescriptions • Media, system and political influences • Personal- individual factors
  97. 97. Self - administration • Knowledge • Skill • Personal-individual factors • Environmental factors
  98. 98. Nurse - administration • Mathematical skills of nurses – Poor mathematical skills in individual nurses can contribute to increasing the risk of error. – Situation may be exacerbated in specialist areas such as paediatrics, where more complex mathematical calculations may be needed to administer drugs. – Calculation error in this speciality is not confined to nurses but is also apparent in health care professional students
  99. 99. Continue… • Nurses actually make conceptual errors related to a particular problem, i.e. they fail to construct a logical approach to dealing with a specific arithmetical problem before the actual calculation is begun.
  100. 100. Knowledge • Nurse’s knowledge should be sufficient to afford competence in the administration of drugs. • The variables that affect level of knowledge include length of experience, and the level and recency of relevant professional education. • Length of nursing experience is not necessarily a significant variable in relation to level of knowledge, neither is educational background, the latter point being further supported by the research. Bindler R. & Bayne T. Medication calculation ability of registered nurses. J Nurs Scholarship 1991;23 (4): 221–224.
  101. 101. • Nurses with more educational qualifications held a better knowledge of medications. • Kawamura: In a Japanese study of 2800 error reports, poor knowledge of recent graduates is identified as a key factor in intravenous drug error. Boggs P, Brown-Molnar CS, De Lapp TD. (1988) Nurse’s Drug Knowledge. Western Journal of Nursing. 1988;10(1):84–93. Kawamura H. (2001) The approaches to factors which cause medication error. Japanese Journal of Cancer and Chemotherapy. 2001;28(3): 304–309.
  102. 102. Length of nursing experience • Practice makes man perfect. If so • are errors being made by experienced staff as opposed to more junior staff? • Years of experience have no bearing on nurse’s mathematical ability in calculating dosages. • Interestingly, experienced nurses tended to have greater confidence in their ability but did not demonstrate a greater ability.s
  103. 103. • Nurses new to either the job or the hospital in which they work are more likely to make errors but are also more likely to report errors. • However, the occurrence of errors increases as the familiarity of the professional administering the drug decreases.
  104. 104. • Staff moving from one clinical area to another may also be susceptible unless they have moved to a very similar setting. • Moreover, length of time qualified cannot be considered in isolation when identifying risk. • During the induction of a new member of staff, the nature of their previous experience should also be analysed in the context of their new responsibilities.
  105. 105. Length of nursing rosters • Type of roster – days, nights, or twilight shifts can contribute towards raising the risk of error. • Several studies have suggested the type of roster and the risk of error. • In mind? • Relationship between number of hours worked and the rate of error. • More medication errors can occur during the day or night
  106. 106. More medication errors can occur during the day??? Simply-logically • Increased number of prescriptions issued and altered or a lower rate of detection during the night, perhaps due to a higher level of fatigue. • It is known that humans are not normally night- active • The nature of error is also different across time zones, – daytime errors more commonly involved wrong drug, dose or preparation; – night-time errors more commonly involved wrong time, rate or administration method
  107. 107. Workload, staffing levels and delivery systems • Important and a sensitive factor. • The politico-legal, and economic ramifications of claiming that more drug errors occur if health professionals are working to a low staff– patient ratio and that some sort of threshold of safety can be established, are significant. • Workload affect error rates.
  108. 108. Conclusion from Roseman and Booker • Assessed the effects of a range of workload factors. • They found errors increased in line with the number of shifts worked by agency staff but errors decreased when shortfalls in staffing levels were covered by permanent staff working extra hours. Roseman C. Booker JM. Workload and environmental factors in hospital medication errors. Nursing Research. 1995:44(4):226–230.
  109. 109. • Taunton et al (1994) claim, as a result of studying patient outcomes – inclusive of drug error, that there is no relationship between medication errors and workload. • It would then be unwise to simply assume that excess workload in terms of extra hours worked has an essentially deleterious effect on the rate of error.
  110. 110. Single nurse administration • Single nurse administration does not necessarily increase the number of errors. • If the variable discusses before is present. Error by single may possible therefore require double check. Don’t you think so?
  111. 111. • Jeanes & Taylor in 1992 reported that single nurse administration does not necessarily increase the number of errors. • Ross et al in 2000 demonstrated that most reported drug errors occurred despite drugs being checked by two practitioners, nevertheless the perception remains that double checking is a robust safeguard against error
  112. 112. Policy and procedure • Absence • Existence • Poor interpretation • Many drug errors arise as a result of failure to follow policy. • Lack of adherence to specific guidelines. • Heavy workload and rapid patient turnover
  113. 113. Distraction and interruptions • Errors is also dependent upon the nature of the clinical setting. • Drugs are often administered in chaotic settings. • Conklin et al 1990 reported in a study based questionnaire to 175 nurses to establish their views on the contributory factors on in drug error and founded that 32% of the sample believed that distractions and interruptions were a key factor.
  114. 114. Quality of prescriptions • Failures in communication can sometimes relate directly to poorly written prescriptions. • Farrar found and reported that the error rate among doctors in writing prescriptions at discharge was 7%. • Lyons et al – 1998- used specific software to scan the legibility of 38 doctors’ handwriting in comparison with 54 other health workers (including 32 nurses). – They found that doctors produced the least legible handwriting but that this was confined to letters rather than numbers.
  115. 115. Methodologies used to study medication errors • Direct observation method – With some confirming the error once the medication administration round had finished (n = 8) – Observation with chart review – Interviews [67] for prospective and retrospective error identification. • Prospective self-reporting methods such as – Log books – error (e.g. incident) reports – drug administration view
  116. 116. • Prospective methods – errors through routine activity or chart review – Interview and blend of all – directly observing staff activity – informal conversations with staff • Retrospective methods – interviews questionnaires/surveys – Focus groups • The presence of an error after the observation period.
  117. 117. • Self-report data
  118. 118. Methodologies used to study medication errors • Prospective chart review • Direct observation • Error reports • Focus groups • Self-report survey • Self-report anonymous questionnaire • Semi-structured individual interviews • Self-report survey questionnaire and chart review • Self-report survey questionnaire, simulation exercises • Questionnaire • Independent review of data.
  119. 119. • informal and formal interviews • Structured interview • Semi-structured interviews and coding • Prospective procedure record dataset • listening to nurse conversations followed by independent review of data • Questionnaire survey— section asking what factors contributed to the incident • Specific question on error with narrative error descriptions • Confidential self- reporting survey tool.
  120. 120. • Staff interviewed by a researcher using both closed- and open-ended questions to determine contributory events and conditions and possible contributory factors. • Direct observation and third party observation
  121. 121. Drugs Commonly Associated with Medication Errors DRUG TYPE EXAMPLES OF COMMON ERRORS Analgesics Over sedation, over dose, Wrong route of administration Failure to monitor heart rate, respiration, and blood pressure Allergic reactions in patients with documented allergy Antibiotics Overuse when symptoms do not warrant use, Wrong antibiotic or dose or both, monitoring failure and allergy documentation Cardiovascular agents Over dose and specific Anticoagulants Inadequate therapeutic dosing, No evaluation of findings from laboratory testing of blood values, such as international normalized ratio Diuretics Overdose, Lack of monitoring electrolytes Diabetic medicine Use in people without diabetes, Overdose of intravenous or injectable medications, including duplicate dosing , Drug substitution or wrong type of insulin, Mistaking for insulin application, brand and storage NSAIDS Extended use, leading to serious gastrointestinal complications such as bleeding and perforation , Overdose because NSAIDs are contained in many over-the-counter products, Taking excessive amounts, leading to hepatotoxicity, acute renal failure, or death
  122. 122. Examples of Situations Requiring Hypervigilance to Avoid Medication Error • Inadequate patient information – Clinical team unaware of known allergies or all current medications taken by the patient • Inability to monitor – Vital signs or laboratory values not checked before calculating dose or administering medication. • Multiple chronic conditions – Failure to recognize abnormal laboratory results and poor diagnosis • Number of medications & unfamiliarity with medication – Patient taking multiple medications misses or doubles a dose – Not doing required follow-up laboratory testing, such as with anticoagulants or antiepileptics • Monitoring effect of treatment • Switching route of administration – Not having a therapeutic dose when switching from IV to PO
  123. 123. • Drug require manipulation – Inaccurate dosing when splitting, crushing, or suspending a medication • Drug dosing require calculation – Miscalculation of dose for age or weight especially when wt and age are discordant – Mistaking teaspoonful for a tablespoonful and vice versa • Handwriting of prescription – Incomplete information – Written for an incorrect dosage form or strength – Illegible order or signature – Decimals leading to mistaken dosing – Nonstandard terminology
  124. 124. • Children – Wrong dose, route, or frequency – Calculation of drug dose depending on weight – Administration of medications to neonates in intensive care – Dosing errors, especially for IV administration • Elderly – Patients taking multiple drugs, having depressive symptoms or poor health status, being female, or making several out patient visits in the past year are at greater risk for medication errors – Patient does not understand and follow the prescribed regimen – Elderly are more sensitive to effects of medication, and adjustments in dose may be necessary. • Women – Women who are pregnant or lactating given medications not approved for them
  125. 125. How to prevent • Recommendations for Preventing Medication Errors. – Organizational and Departmental – Prescribers – Pharmacists – Nurses – Patient and care giver – Pharmaceutical manufacturer
  126. 126. Organizational and Departmental • Organizational policies and procedures should be established to prevent medication errors. • Development of the policies and procedures should involve multiple departments, including pharmacy, medicine, nursing, risk management, legal counsel, and organizational administration.
  127. 127. • The formulary system, the P&T committee should be responsible for formulating policies regarding the evaluation, selection, and therapeutic use of drugs in organized health-care settings. • Care and consideration must be given in hiring and assigning personnel involved in medication ordering, preparation, dispensing, administration, and patient education. Policies and procedures should be developed that ensure adequate personnel selection, training, supervision, and evaluation. • Ensure proper interviewing, orientation, evaluation of competency, supervision, and opportunities for continuing professional and technical education. • Sufficient personnel must be available to perform tasks adequately. Policies and procedures should ensure that reasonable workload levels and working hours are established and rarely exceeded. • Suitable work environments should exist. • Lines of authority and areas of responsibility within the hospital should be clearly defined for medication ordering, dispensing, and administration. • Ongoing, systematic program of quality improvement and peer review with respect to the safe use of medications.
  128. 128. • Responsible staff for processing drug orders should have routine access to appropriate clinical information about patients (including medication, allergy, and hypersensitivity profiles; diagnoses; pregnancy status; and laboratory values) to help evaluate the appropriateness of medication orders. • Pharmacists should maintain medication profiles for all patients, both inpatients and ambulatory patients, who receive care at the hospital. • The pharmacy department must be responsible for the procurement, distribution, and control of all drugs used within the organization. Adequate hours for the provision of pharmaceutical services must be maintained; 24-hour pharmaceutical service is strongly recommended in hospital settings. • In the absence of 24-hour pharmaceutical service, access to a limited supply of medications should be available to authorized nonpharmacists for use in initiating urgent medication orders. • When 24-hour pharmacy service is not feasible, a pharmacist must be available on an “on-call” basis. • The pharmacy manager (or designee), with the assistance of the P&T committee (or its equivalent) and the department of nursing, should develop comprehensive policies and procedures that provide for efficient and safe distribution of all medications and related supplies to patients.
  129. 129. • Except in emergency situations, all sterile and nonsterile drug products should be dispensed from the pharmacy department for individual patients. • The storage of nonemergency floor stock medications on the nursing units or in patient-care areas should be minimized. Particular caution should be exercised with respect to drug products that have commonly been involved in serious medication errors or whose margin of safety is narrow, such as concentrated forms of drug products that are intended to be diluted into larger volumes (e.g., concentrated lidocaine and potassium chloride for injection concentrate). • All drug storage areas should be routinely inspected by pharmacy personnel to ensure adequate product integrity and appropriate packaging, labelling, and storage. • Drug products and other products for external use be stored separately from drug products for internal use. • The pharmacy director and staff must ensure that all drug products used in the organizational setting are of high quality and integrity. • The use of a patient’s own or “home” medications should be avoided to the fullest extent possible. • All discontinued or unused drugs should be returned to the department of pharmacy immediately on discontinuation or at patient discharge. • Discharged patients must not be given unlabeled drug products to take home. • Counsel patient on discharged or take home medicnies.
  130. 130. • Where possible, the use of technological innovations such as bar coding is recommended. • Adequate drug information resources should be available for all health-care providers involved in the drug use process. • Standard drug administration times should be established for the hospital by the P&T committee. • Develop a list of standard abbreviations approved for use in medication ordering. • A review mechanism should be established. • The pharmacy department, in conjunction with nursing, risk management, and the medical staff, should conduct ongoing educational programs to discuss medication errors, their causes, and methods to prevent their occurrence.
  131. 131. Recommendations for Prescribers. • To determine appropriate drug therapy, prescribers should stay abreast of the current state of knowledge through literature review, consultation with pharmacists, consultation with other physicians, participation in continuing professional education programs, and other means. • Prescribers should evaluate the patient’s total status and review all existing drug therapy before prescribing new or additional medications to ascertain possible antagonistic or complementary drug interactions. • prescribers should be familiar with the medication ordering system. • Drug orders should be complete.
  132. 132. • Care should be taken to ensure that the intent of medication orders is clear and unambiguous. • Write out instructions rather than using nonstandard or ambiguous abbreviations. • Do not use vague instructions, such as “take as directed,” • Specify exact dosage strengths (such as milligrams) rather than dosage form units (such as one tablet or one vial). • Prescribe by standard nomenclature, using the drug’s generic name. • Always use a leading zero before a decimal expression of less than one (e.g., 0.5 ml). Conversely, a terminal zero should never be used (e.g., 5.0 ml). • Spell out the word “units” (e.g., 10 units regular insulin) rather than writing “u,” • Use the metric system.
  133. 133. • Written drug or prescription orders (including signatures) should be legible. Prescribers with poor handwriting should print or type medication or prescription orders if direct order entry capabilities for computerized systems are unavailable. • A handwritten order should be completely readable. • Verbal drug or prescription orders (that is, orders that are orally communicated) should be reserved only for those situations in which it is impossible or impractical for the prescriber to write the order or enter it in the computer. • The prescriber shsuld dictate verbal orders slowly, clearly, and articulately to avoid confusion. • When possible, drugs should be prescribed for administration by the oral route rather than by injection. • Observe and instruct special SE/ADR/Allergy • Prescribers should follow up and periodically evaluate the need for continued drug therapy for individual patients. • Practice “hold” and “stop order”
  134. 134. Recommendations for Pharmacists • Participate in drug therapy monitoring • Stay abreast of the current state of knowledge • Offer information and advice about therapeutic drug regimens and the correct use of medications • Familiar with the medication ordering system and drug distribution policies. • Never assume or guess the intent of confusing medication orders • Pharmacists should maintain orderliness and cleanliness in the work area and perform one procedure at a time • Review an original copy of the written medication order. • Use of automated devices is checked by manual or technological means. • Dispense medications in ready to-administer dosage forms whenever possible.
  135. 135. • Review the use of auxiliary labels • Ensure that medications are delivered to the patient-care area in a timely fashion after receipt of orders, according to hospital policies and procedures. • Observe how medications are actually being used in patient-care areas to ensure that dispensing and storage procedures are followed • Review medications that are returned to the department • Preview and provide advice on the content and design of pre-printed medication order forms or sheets. • Maintain records
  136. 136. • Electronic prescribing may help to reduce the risk of prescribing errors resulting from illegible hand writing. • Computer generated and transacted order system eliminates complex issues of transfer of prescription and typographical problems. However, effects of such systems on patient outcomes remain understudied.
  137. 137. Recommendations for Nurses • Familiar with the medication ordering and use System • Review patients’ medications with respect to desired patient outcomes, therapeutic duplications, and possible drug interactions. • Verify order before administration • Follow rule of right. • When standard drug concentrations or dosage charts are not available, dosage calculations, flow rates, and other mathematical calculations should be checked by a second individual
  138. 138. • Verify multiple drug entry and prescription • Understand and explain use, care and caution on the use of devises use in. • Talk with patients or caregivers to ascertain that they understand the use of their medications and any special precautions or observations that might be indicated. • When a patient objects to or questions whether a particular drug should be administered, the nurse should listen, answer questions, and (if appropriate) double check the medication order and product dispensed before administering it to ensure that no preventable error is made
  139. 139. Patients and Personal Caregivers. • Inform and communicate • Feel free to ask question • Learn medicine and use. • Adhere and take medicine.
  140. 140. Pharmaceutical Manufacturers and approving authority • Involve pharmacists, nurses, and physicians in decisions about drug names, labelling, and packaging. • Look-alike or sound-alike trademarked names and generic names should be avoided. • Similar proprietary appearances of packaging and labelling should be avoided, because look- alike products contribute to medication errors.
  141. 141. • Special instructions should be highlighted on labeling. • The most prominent items on the product label should be information in the best interest of safety. • Appropriate packing • Company communicate to health care provider.
  142. 142. Use of technology to minimise error • Health information technologies – electronic prescribing, – electronic health records, – computerized provider order entry (CPOE), – bar coding, – automated drug-dispensing systems, and unit dosing • Potentially reduce medication errors • The most extensively studied of these technologies is CPOE, which has been shown in many studies to reduce medication errors.
  143. 143. Information technology Benefits Barrier Computerized or electronic medical record Provides patient information to guide drug selection and regimen Not widely available or used Reduces errors related to order transcription Systems may be incompatible outside an organization or institutionReduces errors related to use of abbreviations and name confusion Computerized provider order entry Legible prescription Patient data not up to date Integrates drug formularies Provides clinical decision- making support with alerts and reminders as prescriber enters an order High cost of implementation * Double checks an order before it goes forward Not widely available Assists with converting oral to rv doses Prescribing
  144. 144. Take home question • Automated prospective drug utilization review systems? • Electronic medication administration and record system?
  145. 145. Information technology Benefits Barrier Automated dispensing devices (ADD)/ AD unit Holds medications at a specific location and allows dispensing only to a specific patient Not linked with bar coding and electronic information systems Helps to assess the full range of medications a patient is receiving No communication with the prescriber Assesses drug allergies Doesn't fully assess potential interactions because of limited data Identifies inappropriate drug therapies, averting hospitalisations resulting from adverse drug events Ifs specific to the patient Restocking error User's key is necessary for access. User input error Pharmacy review is part of the process. Dispensing
  146. 146. Information technology Benefits Barrier Physical packaging changes Changes appearance of medications to avoid errors associated with similar looking or similarly spelled drugs Cost of repackaging Uses only one name and one look for each drug, or uses standardized labels New packaging may not be in stock Is not mandated Administration
  147. 147. Information technology Benefits Barrier Bar coding Automated record of medication administration to specific patients Check regulatory status Verifies medications and patients? Administration on most drugs Used in dispensing and verification process Cost of scanners Counters the misreading of drug names and dosages Can introduce human error by requiring manual loading of equipment and bar-code verification Limited and scanner bar cod Packaging changes needed for bar codes on unit doses Problematic for doses such as half a tablet Administration
  148. 148. Cases and Example
  149. 149. Photograph showing almost similar looking ampoules of Inj. Ondoc-2 (Ondansetron) and Inj. Tramadoc (Tramadol Hydrochloride) Inj ONDOC-2 (Ondansetron) is manufactured by Morepen Laboratories Ltd. with embossed printing in red colour whereas inj TRAMADOC (Tramadol Hydrochloride) is manufactured by Pharma Concepts, also with embossed printing in red colour • Look-alike medications are identified and stored separately.
  150. 150. HOW SIMILAR IS TOO SIMILAR/EXACT
  151. 151. • Visiting a website for same is easy but working on the same to keep record and put it in practice may difficult. • Flood of medicine in pharmacy: How many will you?
  152. 152. • A patient was administered 80 units of insulin instead of the prescribed 8 units. • The patient required emergency treatment and recovered. • The prescription chart was unclear. The abbreviation ‘U’ was used for unit, which was misread as a 0.
  153. 153. • A newly qualified staff nurse on a hospital ward administered a Medication Dobutamine to a patient via a IVF when it was prescribed to be administered the patient required monitoring, but was not harmed.
  154. 154. • A 78 year old man with human immunodeficiency virus (HIV) accessed our hospital and was brought to our attention in August 2011 for severe renal failure. Clinical history revealed that he had been taking highly active antiretroviral therapy with lamivudine/abacavir and fosamprenavir since 2006. • In April 2011 due to an augmentation in creatinine plasma levels, a reduction in lamivudine dosage to 100 mg/day and the prescription of abacavir 300 mg/day became necessary. • Unfortunately, the patient took both lamivudine and abacavir therefore the association of the two medications (lamivudine/abacavir) lead to asthenia and acute renal failure within a few days. • Conclusions: This case emphasizes the importance about how physicians must pay very careful attention during drug prescription, most particularly, as far as elderly patients are concerned. In fact, communication improvement between physicians and patients can prevent increase of adverse drug reactions related to drug dispensing, with consequential reduction of costs in the healthcare system L. Gallelli et.al. A case of adverse drug reaction induced by dispensing error. Journal of Forensic and Legal Medicine. 2012; 19: 497-498
  155. 155. • A Pittsburgh pharmacist mistranscribes a telephone Rx, which calls for two 0.25-mcg Rocaltrol pills four times per day. Confusing milligrams and micrograms, she writes down two 0.5-mg pills four times per day. The patient receives a dosage more than 2,000 times the recommended maximum. He is now totally disabled, suffering from complex partial seizures. The jury awards him $8 million in compensatory damages.
  156. 156. • A Florida R.Ph. dispenses Cycrin, a female hormone, instead of the Coumadin prescribed. The patient takes the wrong drug for 11 days before his wife discovers the error. Two days later, he suffers a stroke and, subsequently, a heart attack. In a coma, he now resides in a special care facility. The drugstore chain's insurance company agrees to pay $6 million to settle the lawsuit.
  157. 157. • An South Carolina pharmacist dispenses Glynase 6 mg instead of the Ritalin precribed. The patient, a seven-year-old girl, ingests 16 times the recommended Glynase starting dose for adult diabetes patients. She suffers permanent brain damage and is mentally retarded. The jury awards $16 million to care for the child and to punish the drugstore chain.
  158. 158. Disclosure of error • There are few research work has been reported in literature about the error. • We have to think how strong and robust are our reporting systems? – How? – Whom? – When? – Where?
  159. 159. • Disclosure will be continue….
  160. 160. Questions?

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