PharmD Raed Hamed Al-Harbi Medication Safety King Fahad Hospital (KFH) in Madinah

1. Stages of the medication use process and
Medication Errors
PharmD Raed Hamed Al-Harbi
Medication Safety
King Fahad Hospital (KFH) in Madinah
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2. Main Topics
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Stages of the medication use process
Where medication errors occur and how do occur
Definitions
The relationship between Medication Error, ADE & ADR
Classification of Medication Errors
Examples of Medication Errors

3. Stages of Medication Use Process
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4. Where do Errors Occur?
• The medication use process has five stages, and each of
them could be considered as “Error Prone”…
• Physician Ordering
• Transcribing and Verifying of Physician Orders
• Dispensing and Delivering Medications
• Medication Administration
• Monitoring and Reporting of Medication Effects on the
Patient
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5. How Do Medication Errors Occur?
• The provision of drug therapy by a medical provider to a
patient is a complex process.
• Errors can occur at any step along the way, from
prescribing to administering or taking the medicine.
• Common causes of medication error include incorrect
diagnosis, prescribing errors, dose miscalculations, poor
drug distribution practices, drug and drug device related
problems, incorrect drug administration, failed
communication etc.
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7. Stages of Errors…
• Medication Error = Dispensing Error
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8. Stages of Errors…
• Leape et all, reported that
medication errors occur at
different concentrations
depending on the stage of
the medication use
process(1)
• Most medication errors
occur during physician
ordering (39%)
• and medication
administration (38%)(2)
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9. Medication Error
It is any preventable event that may cause or lead to
inappropriate medication use or patient harm while
the medication is in the control of the health care
professional or patient.
it is may be occur in manufacturing, transportation,
storage and system (Including prescribing, dispensing,
preparation, administration, documentation etc).
The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
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10. Types of Medication Error
Actual Error: A mistake in prescribing, dispensing, or
planned medication administration that has occurred.
This error and may or may not cause
patient harm, require further monitoring, require
hospitalization or extension of hospital stay, cause life-
threatening situation and/or death.
Potential Error: Circumstances or events that have the
capacity to cause error.
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11. Types of Medication Error
Harm: Death, or a temporary or permanent impairment of body
function/structure which requiring intervention.
Near Miss: An actual or potential medication error that did
and did not cause harm.
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12. • Adverse Drug Event (ADE):
defined as harm associated with any dose of a drug, whether
the dose is “normally used in man” or not.
• Adverse Drug Reaction (ADR):
defined as harm that results from a medication dose that is
“normally used in man.”
The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
ADE & ADR
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13. The relationship between Medication Error,
ADE & ADR
• A preventable ADE:-
(medication-related harm due to error)
(e.g., patient given a normal dose of drug but the drug was
contraindicated in this patient).
• A Non-preventable ADE:-
(medication-related harm not due to error)
(e.g., anaphylaxis from penicillin in a patient and the patient
had no previous history of an allergic reaction).
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14. The relationship between Medication Error,
ADE & ADR
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15. Medication Error classification
A- According to step in which we deal with
medication or during which time it is occur
B- According to category or which type of
medication error occur
C- According to medications error severity
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16. A- According to step
Prescribing
Transcribing/Documenting
Dispensing
Administering
Monitoring
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17. A- According to step
• Major Areas for Medication Error:
Prescribing
Dispensing
Administration
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18. Prescribing Errors
• It is an incorrect drug selection for a patient.
• Such errors can include  the dose, strength, route of
administration, quantity, indication, duration, rate of
medication administration or prescribing contraindicated drug.
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19. B- According to category
Wrong DurationWrong Medication
Duplicate TherapyDose Omission
Missed DrugExtra Dose
Drug-Drug InteractionMissed Dose
Wrong Strength or ConcentrationWrong Dose
Unnecessary DrugWrong Administration
Wrong PatientWrong Frequency
Expired MedicationIncomplete/Wrong Label
Wrong IdentificationWrong Storage
Wrong Dosage Form
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20. Example of Wrong Frequency
• Ranitidine IV & Tab
• Cefuroxime IV & Oral (Tab + Suspension)
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21. Example of Wrong Frequency
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22. Example of Wrong Medication
• Physician order Diovan 160mg od in MAR
sheet but she encode Telmisartan 160mg od
(Micardis) on system.
• “Diovan = Valsartan”
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23. Example of missed drug
• Patient taking dual antiplatlets (Aspirin &
Clopidogrel) w/o ulcer prophylaxis.
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24. B- According to category
• Most frequently reported types of medication
errors:-
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25. B- According to category
• Types of reported medication errors that most
frequently caused harm:-
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26. C- According to Severity
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27. Example
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28. Scenario 1
• A M 15 years old male present to ER with abdominal pain and
vomiting, Physician prescribe for him Diclofenac sodium 50 mg
Po BID for 3 days and metoclopramide 10mg Po TID for 3 days.
after 2 hours he came back to ER with bronchospasm. Patient
has history of asthma.
Q- At what step did this medication error occur?
A- prescribing
B- dispensing
C- administration
D- documentation
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29. Continue Scenario 1
• Q2- What is the type of this medication error (diclofenac sodium)?
a- wrong duration
b- wrong drug (incorrect drug selection)
c- wrong dose
d- wrong route of administration
• Q3- What is best description for this adverse drug event
(Bronchospasm)?
A- Preventable ADE
B- non-preventable ADE
C- ADR
D- A & C
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30. Scenario 2
• R M 14 years old male was diagnosed with Bacterial
sinusitis. Physician prescribe to him azithromycin 250 mg
Po BID for 3 days with paracetamol 500mg Po TID for 3
days.
• Q1- What is the type of this medication error?
A- wrong dose
B- wrong drug
C- wrong frequency
D- drug-drug interaction
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31. Continue Scenario 2
• In previous patient after 2 hours from taking his
medications, he suffer from allergy symptoms and he
came back to ER.
• Q2- What is best description for this situation?
A- adverse drug event (ADE)
B- adverse drug reaction (ADR)
C- medication error (ME)
D- both A & B
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32. Scenario 3
• F A 56 years old female diagnosed with HTN, and she was on
amlodipine 10 mg Po once daily. One day she took 3 tabs on
same day in different time by mistake, after 3 hours she
presented to ER with severe hypotension and unconscious status.
• Q- What is the type of this medication error?
A- wrong frequency
B- wrong route of administration
C- wrong dose
D- missed dose
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33. Example of a Prescription ,, what do you see?
• Clopidogrel (Plavix) 75mg Po Od
• Simvastatin (Zocor) 40mg Po Od
• Amlodipine (Amlor) 10mg Po Od
• Aspirin 81mg Po Od
• Perindopril arginine (coversyl) 5mg Po BID
• Paracetamol 1 g IV TID
• Piperacillin-Tazobactam (Tazocin) 4.5g IV q 8 hr
• Ciprofloxacin (Cipro) 400mg IV q 8 hr

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35. Conclusion
The important thing to do after
detecting medication error is
correcting it & make Report about it
To Prevent medication errors from
happening again and enhance
patient safety by learning from
failure of the health care system
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36. Conclusion
We care about HOW? Not WHO?
and there is big difference.
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