4. The Extent of the Medications Error
problem
In the Institution of Medicine report:
44,000 to 98,000 Americans die each year from
medical error, with an associated cost of$17 to
$29 billion.
4
7. Note: In Figures 9–12, the abbreviations stand for the following: “Proc” for the procurement node; “Presc” for the prescribing node;
“Trans/Doc” for
the transcribing/documenting node; “Disp” for the dispensing node; “Admin” for the administering node; and “Monit” for the monitoring
node.
Types of Medication Errors (cont.)
الدوائية األخطاء أنواع(تابع)
Comparison of Medication Error Reports by Process Node
7
The six nodes are
(1) procurement
(2) prescribing;
(3) transcribing/documenting;
(4) dispensing,
(5) administering,; and
(6) Monitoring medication.
http://www.unmc.edu/rural/documents/pr06-08.pdf
10. 3. Dispensing Error
الدواء صرف في خطأ
• Dispensing errors occur at a rate of 5-8
% wrong strength or product.
10
11. 3. Dispensing Error (cont.)
صرف في خطأالدواء(تابع)
Example of Dispensing of LASA
Factor: 7,8 (R and P) ,9,10,13.
Exjade (Deferasirox) once daily # Ferriprox
(Deferiprone)Three Times per day.
Methotrexate frequency is per week not
daily.
Pen G Sodium (IV) # Pen G benzathine(IM)
Ampho B # Ampho B liposomal (not equal)
Alprostadil Inj # Prostaglandin E2 Tablet.
11
13. Administer the medication
Evaluate the patient
Review warning, interaction & allergy
Confirm the transcription
Review the prescription orderSteps of medication
administration:
13
4. Administration Error
خطأإعطاء فيالدواء
14. Contributing factors to drug administration errors
include :
• A failure to check the patient’s identity
• Storage of similar preparations in similar areas.
14
4. Administration Error
خطأإعطاء فيالدواء
15. 4. Administration Error (cont.)
الدواء إعطاء في خطأ(تابع)
The intravenous route of administration
is a particularly complex process
during which errors frequently occur
15
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22. PROPHYLACTIC AB
• Cefazolin over 5 minutes
• Clindamycin / gentamicin / metronidazole:
30 minutes
• Ciprofloxacin: 1 hour
• Within one hour to start operation Or wound
infection will occur
22
23. 4. Administration Error (cont.)
الدواء إعطاء في خطأ(تابع)
Unauthorized Drug error:
23
Example of administration of a
discontinued drug :
The physician prescribe captopril: hold
Captopril if BP <90 mmHg but the Nurse
administered the Captopril while the patient
BP is 80 mmHg. The patient transfer to the
Critical Care Unit.
24. 24
A 3-day-old infant weighing 1.3 kg was prescribed total
parenteral nutrition containing 1 unit of regular insulin per each
327-mL bag. A pharmacy technician mistakenly added 1 mL of
regular insulin (100 units) rather than 1 mL of a pharmacy-
prepared dilution of 1 unit/mL regular insulin. The mistake was
caught 2 hours later when the infant's blood glucose measured 3
mg/dL. Rapid treatment with dextrose boluses ensued, and the
blood glucose returned to normal within 12 hours.
4. Administration Error (cont.)
الدواء إعطاء في خطأ(تابع)
25. 4. Administration Error (cont.)
الدواء إعطاء في خطأ(تابع)
Types of Administration errors (cont.):
Wrong Dosage Form Error :(plain aspirin
instead of enteric-coated)
Wrong Time Error: (in 30-minute window
medications)
25
5
26. A covering physician admitted a patient with
Hodgkin’s lymphoma to a medical unit. At home, the
patient had been taking hydromorphone 2 to 4 mg
orally for pain. The covering physician prescribed the
same medication, but also wrote an order for
hydromorphone 2 to 4 mg IV every 3 hours for pain
if the patient was unable to tolerate oral fluids.
26
Categorization of Medication Error
according to the severity (cont.)
27. Like the physician, the nurses on the unit did not recognize
that oral and IV dosing of this product, as with most opiate
analgesics, is quite different. In converting an oral
hydromorphone dose to IV, the generally accepted
equianalgesic dose is between 3 to 1 and 5 to 1. A nurse
administered 4 mg IV and the patient developed respiratory
depression and became unresponsive. Two doses of
naloxone IV reversed the effects of the medication.
27
Categorization of Medication Error
according to the severity (cont.)
Editor's Notes
.
Wrong Dosage Form Error: The administration of a medication in a dosage form different from the one that was ordered by the prescriber. This could include crushing a tablet prior to administration without an order from the prescriber.
If enteric-coated aspirin was ordered, but plain aspirin was administered, a wrong form error was counted.
Wrong Time Error: The failure to administer a medication to a patient within one (1) hour from its scheduled administration time. The standard hospital administration time as approved by the Pharmacy and Therapeutic Committee is considered the reference.
Administration time of a dose must not be more than 60 minutes before or after the scheduled administration time. A 30-minute window was used for medications that were ordered before, with, or after a meal.
Routine administration times were obtained from each site, and times assigned on the MAR were used when no other policy was available.
Wrong Drug Preparation Error: such as
incorrect or inaccurate dilution or reconstitution,
failure to shake suspension,
crushing medication that should not be crushed, mixing drug that is physically or chemically incompatible and inadequate product packaging.
Wrong Administration Technique Error: Use of an inappropriate procedure or improper technique in the administration of a drug. Examples of wrong technique error include; incorrect manipulation of inhalers, failure to maintain sanitary technique with medications, not wiping an injection site with alcohol, failure to use proper technique when crushing medications, failure to check nasogastric (NG) tube placement or flushing NG tube before and after administration of medication, failure to wash hands or improper hand washing technique used.
It is defined also defined as: Exclusion of or incorrect performance of a procedure ordered by the prescriber immediately before administering each dose of medication. Examples of this error include the lack of heart rate or blood pressure measurement before giving a dose.
Wrong Patient Error:
such as identification not properly verified, or patients with look-alike name.
Wrong Duration Error:
such as not adhering to the proper schedule of administration,
