DefinitionWhat to/ not to reportME TypesME Reporting Flow ChartME Report FormME ExamplesError Reduction Strategies
Any preventable event that maycause or lead to inappropriatemedication use or patient harmwhile the medication is in control ofthe healthcare professional, patientor consumerNCCMERP, USDEFINATION MEDICATIONERROR . .
When errors are common, Health Care isHazardous.We need to reduce the risk of error,predominantly by improving systems.Accepting that errors cannot be eliminated, weneed toEncourage reportingLearn from errorsManage the repercussions to the patient,caregivers, and any other affected groups.
Non-punitiveAll levels of healthcareproviders may report Involve both publicand private sectorsIncludes hospitals,clinics,community pharmacies
Maybe related to professional practice,healthcare products, procedures andsystems including:prescribing, order communication,product labeling, packaging,compounding, dispensing, distribution,administration, monitoring and use6
Medication errors can becommitted (or contributed to) byAnyone who handles medicinePhysicians/doctors, dentists,pharmacists, other healthcareproviders, patients, caregivers etc
Error is inevitable because of humanlimitations- Limited memory capacity- Limited mental processing capacity- Negative effects of fatigue and otherphysiological stressors
Look at systems involved inmedication errorWhy?and not Who?
Risks that can lead to errors or nearmissesSound-alike names or look alikepackagesAmbigous product labelsUse of error prone abbreviationsError-prone functions in cpoe systems
1. Look alike drugs which can be interms of product size, packaging andalso colour on the label, example ;
3. Illegible handwriting, which may lead tomisinterpretation of doctor’s prescriptionsuch as drug’s name, dosage, frequency,example;
Medication error can be broadly classified as :Prescribing errorsDispensing errorsAdministration errors
Inadequate knowledge about drug interaction &contraindicationNot considering individual patient factor-E.g. allergies,pregnancy,co-morbidities,othermedMiscommunication(written,verbal)Documentation-illegible,incomplete,ambiguousIncorrection calculationIncorrect data entry when using computerizedPhysian Order Entry(CPOF)
Wrong stock selectionSelf-checkingIncorrect storage of medicines,wrong shelf,etcNot following checking protocolsStaff distractionToo many tasks at onceToo few staffPoorly trained staffBad communication between staff
Wrong patientWrong drugWrong timeWrong doseWrong routeOmission,failure to administer
PrescribingPrescribingerrorerrorIncorrect drug productIncorrect drug productselection (based onselection (based onindications, CI,knownindications, CI,knownallergies, existing drugallergies, existing drugtherapy), dose,dosagetherapy), dose,dosageform, quantity, route orform, quantity, route orrate of administration,rate of administration,conc, or instructions forconc, or instructions foruse authorised byuse authorised byphysician; illegible Rx orphysician; illegible Rx ormed orders that lead tomed orders that lead toerrorserrors
OmissionOmissionerrorerrorThe failure to administerThe failure to administeran ordered dose to aan ordered dose to apatient before the nextpatient before the nextordered dose or failure toordered dose or failure toprescribe a drug productprescribe a drug productthat is indicated.that is indicated.The failure to administerThe failure to administeran ordered dose excludesan ordered dose excludespatient’s refusal andpatient’s refusal andclinical decision or otherclinical decision or othervalid reason not tovalid reason not toadminister.administer.
Wrong timeWrong timeerrorerrorUnauthorised/Unauthorised/wrong drugwrong drugerrorerrorAdministration ofAdministration ofmedication outside amedication outside apredefined time intervalpredefined time intervalfrom its scheduledfrom its scheduledadministration timeadministration timeDispensing orDispensing oradministration to theadministration to thepatient of medication notpatient of medication notauthorised by a legitimateauthorised by a legitimateprescriberprescriber
Dose errorDose error Dispensing or administrationDispensing or administrationto pt of a dose that is > or<to pt of a dose that is > or<than amount ordered bythan amount ordered byprescriber or administrationprescriber or administrationof multiple doses to ptof multiple doses to ptDosage formDosage formerrorerrorDispensing or administrationDispensing or administrationto pt of a drug product into pt of a drug product indiff dosage form than thatdiff dosage form than thatordered by prescriberordered by prescriber
DrugDrugpreparationpreparationerrorerrorDrug product incorrectlyDrug product incorrectlyformulated or manipulatedformulated or manipulatedbefore dispensing orbefore dispensing oradministrationadministrationRoute ofRoute ofadministrationadministrationerrorerrorWrong route ofWrong route ofadministration of theadministration of thecorrect drugcorrect drugAdministrationAdministrationtechniquetechniqueerrorerrorInappropriate procedure orInappropriate procedure orimproper technique in theimproper technique in theadministration of a drugadministration of a drugother than wrong routeother than wrong route
DeterioratedDeteriorateddrug errordrug errorDispensing or administrationDispensing or administrationof a drug that has expired orof a drug that has expired orthe physical or chemicalthe physical or chemicaldosage form integrity hasdosage form integrity haschangedchangedMonitoringMonitoringerrorerrorFailure to review aFailure to review aprescribed regimen forprescribed regimen forappropriateness & detectionappropriateness & detectionof problems, or failure to useof problems, or failure to useappropriate clinical or labappropriate clinical or labdata for adequatedata for adequateassessment of pt response toassessment of pt response toprescribed therapyprescribed therapy29
ComplianceComplianceerrorerrorInappropriate patientInappropriate patientbehavior regardingbehavior regardingadherence to a prescribedadherence to a prescribedmedication regimenmedication regimenOtherOthermedicationmedicationerrorerrorAny medication error thatAny medication error thatdoes not fall into one of thedoes not fall into one of theabove predefined typesabove predefined types
18. Medication Error (ME) Reporting FormMEDICATION ERROR (ME) REPORTING FORMReporters do not necessarily have to provide any individual identifiable health information, including names ofpractitioners, names of patients, names of healthcare facilities, or dates of birth (age is acceptable)1. Date of event Time of event Place /Location of event2. Please describe the error. Include description/sequence of events, type of staff involved, andwork environment (e.g. change of shift, short staffing, during peak hours). If more space isneeded, please attach a separate page.3. Did the error reach the patient? (Tick appropriate box) Yes No4. Was the incorrect medication, dose or dosage formadministered to or taken by the patient? (Tick appropriate box) Yes No4 .1 Circle the appropriate Error Outcome Category (select one – see Guide for details)A B C D E F G H I4 .2 Describe the direct result on the patient (e.g., death, type of harm, additional patientmonitoring).5. Indicate the possible error cause(s) and contributing factor(s) (e.g., abbreviation, similarnames, distractions, etc).6. What category of staff or healthcare provider made the initial error?7. Indicate if other provider (s) were also involved in the error (category of staff perpetuatingerror)32
Date and time of eventType of facilityPrivate/ governmenthospital/clinic/pharmacyLocation of event:- ward- pharmacy- A& E- OT/ ICU etc
Description of event- sequence of events- work environment (peak hour, change ofshift)- details (what? how? of the incident)Attach separate page if more space is needed
In which process error occurPrescribing/Dispensing/Administration/OthersDid error reach patient Y/NIncorrect med, dose or dosage administeredor taken by patientDescribe direct result on patienteg. death, admission into hospital, drugsprescribed to treat error
Did an actual erroroccur?Category CCircumstances or events thathave the capacity to causeerrorDid the error reach thepatient? *Did the error contribute to orresult in patient death?Was the patient harmed?Did the errorrequire an intervention necessaryto sustain life ?Did the error require initialor prolonged hospitalizationWas the harm temporary?Was the harm permanent ?Category HCategory GCategory E Category FWas intervention topreclude harm or extramonitoring required ?Category BCategory ACategory ICategory DNONONONONONONOYESYESYESYESYESNOYESYESNOYESYESClassification of Medication Error SeverityClassification of Medication Error SeverityNO ERRORNO ERRORCategory ACategory A Potential error, Circumstances/events havePotential error, Circumstances/events havepotential to cause incidentpotential to cause incidentERROR, NO HARMERROR, NO HARMCategory BCategory B Actual Error – did not reach patientActual Error – did not reach patientCategory CCategory C Actual Error – caused no harmActual Error – caused no harmCategory DCategory D Additional monitoring required – caused noAdditional monitoring required – caused noharmharmERROR HARMERROR HARMCategory ECategory E Treatment/Intervention required –causedTreatment/Intervention required –causedtemporary harmtemporary harmCategory FCategory F Initial/prolonged hospitalization –causedInitial/prolonged hospitalization –causedtemporary harmtemporary harmCategory GCategory G Caused permanent harmCaused permanent harmCategory HCategory H Near death eventNear death eventERROR, DEATHERROR, DEATHCategory ICategory I DeathDeathAn error of omission does reach theAn error of omission does reach thepatientpatientAll ME reports should be sent to :Medication Safety CentrePharmaceutical Services Division , Ministry of HealthP.O. Box924, Jalan Sultan,46790 Petaling Jaya, Selangor.19. GUIDE FOR CATEGORIZING MEDICATION ERRORS37
Possible contributing factor (s)Example:- Sound alike or look alike drug- Look alike packaging- Different strength of same drug- Unclear instruction on Rx- Illegible handwriting
Category of staff made initial error?Other category involvedCategory of staff,provider orindividual who discovered theerror/potential errorExample: Doctor, pharmacist, staffnurse, pharmacist assistant, asstmedical officer, PRP, trainee MA or SN
Patient’s particularsDo not provide patient’s nameInfo needed = age, M or F, diagnosisProduct 1 intended (prescribed)/ errorbrand name, generic name, dose,freq,duration, routesimilar packaging- manufacturer, dosageform, strength, container type
Relevant materials can be provided- copy of Rx, label of product, picture ofproduct involvedRecommendations/ preventive actionstakenReporter’s details
Administrative errorsExamples: no prescribers stamp no countersignature for categoryA medicines Medicines not stocked
Tall Man LetteringWriting part of a drugs name in uppercase letters to help distinguish soundalike, look alike drugs from one anotherniMODIpine - niFEDIpineMETOprolol - BISOprololpredniSONE – prednoso LONECurrently the Pharmacy Department haslabeled the drug bins using this format
Medication Error AlertAlerts should be issued out whenevererrors occur so that the information willbe disseminated for others to be morecareful in dealing with the medicationinvolved.This alerts can be issued via emails,memo and also posters.
Poster of product changeCirculate posters on product changes sothat all pharmacy staff will know thatcertain medications had changed inappearance.
Colour-coded binsThe bin label is differentiated accordingto pharmacological group.The colour coding concept is adaptedfrom 5S Guidelines 2011 published by thePharmaceutical Service Division, Ministryof Health Malaysia.
Prompt alert in e-HISPrompt alert in the e-HIS were createdfor medications which has potential ofbeing mistakenly prescribed by doctors.Most of the drugs involved aremedication which sound alike.
Enable the healthcare providers & institutions tolearn about :• Potential risks - Risk hidden in the processes used• Actual errors - Errors that happen during patientcare• Causes of errors - Underlying weaknesses insystems & processes that explain why errorshappened• Prevention - Ways of preventing recurrent events
THANK YOU FORYOUR ATTENTIONMEDICATION ERRORS ARE PREVENTABLE!
What are the types of medication error? Give 3examples.What are the steps taken to overcome this error?Name 2 of them.