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Medication Safety
The document describes a case of medication error where a patient was wrongly administered pancuronium instead of an antacid, causing respiratory arrest. It provides definitions of medication error and discusses the prevalence and impact of medication errors. It identifies common types of errors like wrong dose, wrong drug or wrong route. Contributing factors discussed include look-alike packaging, sound-alike names, distractions, workload and abbreviations. Strategies to prevent errors include separating high-alert medications, tall man lettering, double checks and education.
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Medication Safety
- 1. Jabatan Farmasi Institut KanserNegara MEDICATION SAFETY
- 2. Richard Smith,who had a history of kidney disease, had been admitted to the ICU after a dialysis session where he experienced severe shortness of breath. The next day, July 30, 2010, he complained of an upset stomach, so the doctor prescribed the antacid. The day his daughter came by to visit that morning, and found his dad "unconscious, unresponsive and on a respirator.“ "The nurse said my dad had coded. I said, 'He coded? When did that happen?‘” The doctor told him, "I'm sorry to have to tell you this but the nurse administered the wrong medication and sent your dad into respiratory arrest.“ "He said the packaging looked the same and he grabbed the wrong package,“ The nurse is wrongly given pancuronium instead of antacid. UPSET STOMACH TO CODE RED
- 4. MEDICATION ERROR -DEFINITION “A medication error 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, patient, or consumer. National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP, US)
- 5. TO ERR ISHUMAN: BUILDING A SAFER HEALTH SYSTEM
- 6. Healthcare is nearly 10years behind other industries in its efforts to reduce errors. Michael A. Jackson, BS Pharm, RPh Wesley G. Reines, PharmD
- 7. “MEDICATION ERROR : SIMPLEMISTAKE CAN BE LETHAL” Medication Safety Is Everyone’s Responsibilities “PLEASE DO NO HARM”
- 8. MEDICATION ERROR: WHY THECONCERN? The impact of medication safety incidents on patient outcomes includes increased length of stay, disability and mortality ( V i n c e n t e t a l . , 2 0 0 1 , U K ) Medication errors are estimated to account for at least 7,000 deaths in the United States alone every year. Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999, p. 1 . Over 770,000 patients are estimated to be injured because of medication errors every year. A g e n c y f o r H e a l t h R e s e a r c h a n d Q u a l i t y , 2 0 0 1 At least 1 death occurs per day and 1.3 million people are injured each year due to medication errors. Food and Drug Administ rat ion (FDA), US Medication error is one of the most common causes of unintentional harm in Australia which results in an estimated 80,000 hospital admissions every year ( S e n a t o r K a y P a t t e r s o n , F e d e r a l M i n i s t e r f o r H e a l t h a n d A g e i n g A u s t r a l i a , 9 S e p t e m b e r 2 0 0 3 )
- 9. MEDICATION ERROR: WHY THECONCERN? Medication errors occur in nearly 1 out of every 5 doses given to patients in the typical hospital. ( R e f e r e n c e : B a r k e r K N , F l y n n E A , P e p p e r G A , P h D , B a t e s D W , M i k e a l R L . M e d i c a t i o n e r r o r s o b s e r v e d i n 3 6 h e a l t h c a r e f a c i l i t i e s . A r c h I n t e r n M e d 2 0 0 2 ; 1 6 2 : 1 8 9 7 - 1 9 0 3 . ) One 5-year study showed that the most common types of medication errors were a wrong dose, a wrong drug or a wrong route of administration. ( R e f e r e n c e : P h i l l i p s J , B e a m S , B r i n k e r A , H o l q u i s t C , H o n i g P , L e e L Y , P a m e r C . R e t r o s p e c t i v e a n a l y s i s o f m o r t a l i t i e s a s s o c i a t e d w i t h m e d i c a t i o n e r r o r s . A m J H e a l t h S y s t P h a r m . O c t 2 0 0 1 . 5 8 ( 1 9 ) ; 1 8 3 5 - 4 1 ) Adverse medication events have been reported and are estimated to occur at a rate of around 5% for admissions and discharges from the typical hospital. ( R e f e r e n c e : C l a s s e n D C , P e s t o n i k S L , E v a n s R S , L l o y d J F , B u r k e J P . A d v e r s e d r u g e v e n t s i n h o s p i t a l i z e d p a t i e n t s . J A M A 1 9 9 7 ; 2 7 7 : 3 0 1 - 3 0 6 . L a z a r o u J , P o m e r a n z B H , C o r e y P N . I n c i d e n c e o f a d v e r s e d r u g r e a c t i o n i n h o s p i t a l i z e d p a t i e n t s . J A M A 1 9 9 8 ; 2 7 9 : 1 2 0 0 - 1 2 0 5 . ) Several studies point to more than 50% of potential and serious adverse events being associated with injectable medications. (R e f e r e n c e : K a u s h a l R , B a t e s D W , L a n d r i g a n C , e t a l . M e d i c a t i o n e r r o r s a n d a d v e r s e d r u g e v e n t s i n p e d i a t r i c i n p a t i e n t s . J A M A 2 0 0 1 ; 2 8 5 : 2 1 1 4 - 2 1 2 0 . T h o m a s E J , B r e n n a n T A . I n c i d e n c e a n d t y p e s o f p r e v e n t a b l e a d v e r s e e v e n t s i n e l d e r l y p a t i e n t s : p o p u l a t i o n b a s e d r e v i e w o f m e d i c a l r e c o r d s . B M F 2 0 0 0 ; 3 2 0 : 7 4 1 - 7 4 4 . )
- 10. MEDICATION ERROR: WHY THECONCERN? The extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year. This estimate does not take into account lost wages and productivity or additional healthcare costs " P r e v e n t i n g M e d i c a t i o n E r r o r s : Q u a l i t y C h a s m S e r i e s ” , I O M R e p o r t , J u l y 2 0 0 6 IOM issued a report on the prevalence of medication errors in the United States in which at least 1.5 million Americans are injured every year by medication errors.
- 11. Martin A Makary,and Michael Daniel BMJ. 2016;353:bmj.i2139
- 12.
- 13. WHERE CAN MEDICATIONERROR OCCUR? Medication error 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”
- 15. Prescribing Transcribing DispensingAdministering Medication Management Processes Errors • Wrong Dose • Wrong Drug • Wrong Route/Form • Allergy • Drug Interaction • Wrong Dose • Wrong Drug • Wrong Route • Wrong Time • Wrong Patient • Wrong Dose • Wrong Drug • Wrong Route • Wrong Time • Wrong Patient • Incorrect Labelling • Primary Catch for allergy, drug interaction • Wrong Dose • Wrong Drug • Wrong Route • Wrong Time/ Omitted • Wrong Patient • Incorrect Labelling
- 16. MEDICATION SAFETY ISEVERYONE’S RESPONSIBILITIES The Pharmaceutical Services Division has always placed emphasis on medication safety and its strategies are in line with those of the Patient Safety Council of Malaysia Strategies to Improve Medication Safety Reporting & Learning Dissemination of Information Guidelines Education & Empowerment
- 18. MEDICATION ERROR REPORTS Current medication error are reported to: United States Pharmacopeia ISMP Medwatch reports Manufacturer reports UK : National Reporting and Learning System (NRLS), National Patient Safety Agency (NPSA) Australia : NSW Health Incident Information Management System(IIMS), Queensland Health Clinical Incident Information System (PRIME CI) in Queensland Malaysia : MERS
- 19. MEDICATION ERROR REPORTINGSYSTEM (MERS)
- 20. MEDICATION ERROR (ME)REPORTING SYSTEM (MERS) Purpose: a) To obtain information on the occurrence of medication errors b) To maintain a database on medication errors c) To analyse the report d) To propose remedial actions and monitor the situations e) To minimize the reoccurrence of such errors
- 21. NUMBER OF MEREPORTS RECEIVED BY YEAR 2572 4120 5003 6011 8422 16897 43025 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 0 5000 10000 15000 20000 25000 30000 35000 40000 45000 50000
- 22. PROCESS IN WHICHTHE ERROR OCCUR 2387 3568 3290 4017 5229 13056 139 421 1131 1433 2645 3301 44 84 407 416 398 326 2 5 41 37 31 32 0 42 134 108 119 182 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 Combination Others Administration Dispensing Prescribing
- 23.
- 24. CONTRIBUTING FACTORS OFME 12003, 48% 8759, 35% 3066, 12% 1106, 5% 2014 Staff Factors Work Environment Task & Technology Medication Related
- 25. Contributing Factors Noof Reports Total Medication Related Look alike medication 317 1106 Look alike packaging 337 Sound alike medication 452 Staff Factors Distraction 3455 12003 Inadequate knowledge 2369 Inexperienced personnel 6179 Task & Technology Failure to adhere to work procedure 1647 3066 Illegible prescription 646 Incorrect computer entry 101 Patient information/record/ unavailable/ inaccurate 507 Use of abbreviations 165 Work & Environment Heavy workload 2566 8759 Peak hour 5492 Stock arrangements/ storage problem 260 Wrong labeling/ instruction on dispensing envelope or bottle/ container 441
- 27. ERROR-PRONE ABBREVIATION Abbreviation Intendedmeaning Common Error U Units Mistaken as a zero or a four (4) resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written. µg Micrograms Mistaken for "mg" (milligrams) resulting in an overdose. Q.D. Latin abbreviation for every day The period after the "Q" has sometimes been mistaken for an " I, " and the drug has been given "QID" (four times daily) rather than daily. Q.O.D. Latin abbreviation for every other day Misinterpreted as "QD" (daily) or "QID" (four times daily). If the "O" is poorly written, it looks like a period or "I."
- 28. ERROR-PRONE ABBREVIATION Abbreviation Intendedmeaning Common Error SC or SQ Subcutaneous Mistaken as "SL" (sublingual) when poorly written. D/C Discharge; also discontinue Patient's medications have been prematurely discontinued when D/C, (intended to mean "discharge") was misinterpreted as "discontinue," because it was followed by a list of drugs. IU International Unit Mistaken as IV (intravenous) or 10(ten)
- 29. MMF –MTF HCT – HCTZ – HCQ CBZ – CPZ IVIg vs Human Albumin ERROR-PRONE ABBREVIATION
- 30. HOW TO PREVENTERROR? Use generic names for drug. Avoid trade names. Avoid using abbreviations Write clear instructions Daonil Glibenclamide X √ MTF Metformin X √ Gutt. CMC BD Gutt. CMC 2 drops RE BD X √
- 31. HOW TO PREVENTERROR? Use leading zero before decimal point Avoid trailing zero after decimal point Avoid verbal orders Identify patient drug allergies .5 mg 0.5 mg X √ 5.0 mg 5 mg X √
- 33. LOOK ALIKE SOUNDALIKE MEDICATIONS (LASA) Medications that are: Visually similar in physical appearance or packaging Name of the medications that have spelling similarities
- 34. Inj. Vitamin K1mg/ml Inj. Neostigmine Inj. Vitamin K 10mg/ml
- 35. SOUND ALIKE MEDICATIONS Clotrimazole – Co-trimoxazole Oxycontin - Oxynorm Dopamine - Dobutamine Adrenaline - Atropine Noradrenaline – Adrenaline
- 36. HOW TO PREVENTERROR? Double checking the drug (dispensing/administering) (Pharmacist) Contacting the prescribers in case of any clarification regarding the prescription (DO NOT ASSUME) Becoming familiar with LASA medications Separating LASA medications from one another Using Tall Man Lettering Installing warning system to staff – Computer alerts or warnings on stock bottles
- 37. SEPARATING LASA MEDICATIONSFROM ONE ANOTHER
- 38.
- 39. TALL MAN LETTERING NoMedication No Medication No Medication No Medication 1 ATRAcurium 13 DOBUTamine 25 LOsartan 37 PANTOprazole 2 BISOprolol 14 DOXOrubicin 26 LOVAstatin 38 PERINDOpril 3 BUPIvacaine 15 DOPamine 27 metFORMIN 39 progyLUTON 4 carBAMAZepine 16 DuphASTON 28 METOprolol 40 ProgyNOVA 5 carBIMazole 17 DuspaTALIN 29 NEostigmine 41 ProSCAR 6 cefOTAXime 18 ENALApril 30 NeuroBION 42 PROzac 7 cefTAZIDime 19 ESOMEprazole 31 NeuroNTIN 43 ROcuronium 8 cefTRIAXone 20 FORTzaar 32 niFEDipine 44 ROPIvacaine 9 chlorproMAZINE 21 gliBENclamide 33 niMODipine 45 SETRAline 10 chlorproPAMIDE 22 gliCLAzide 34 nitroGLYCERINe 46 STELLAzine 11 COzaar 23 LANSOprazole 35 nitroPRUSSIDe 47 VEcuronium 12 DAUNOrubicin 24 LIGNOcaine 36 PANcuronium 48 vinBLAStine
- 40.
- 41.
- 42. FENTANYL PATCH -HOW TO CUT Needs to be cut DIAGONALLY 6 MCG/HR 6 MCG/HR Only for 6mcg/hr dose For 12mcg/hr dose, use 25mcg/hr patch (cut into half) 12 MCG/HR 12 MCG/HR
- 43. FENTANYL PATCH -HOW TO ADMINISTER 12 MCG/HR DOSE HOW TO ADMINISTER 6 MCG/HR FOR 3 DAYS ½ patch 12mcg/hr 18 MCG/HR FOR 3 DAYS ½ patch 25mcg/hr + ½ patch 12mcg/hr 6mcg/hr 6mcg/hr12mcg/hr +
- 44. Guide OnHandling Look Alike Sound Alike Medications
- 45. HIGH ALERT MEDICATIONS(HAMS) Drugs that bear a heightened risk of causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients. Institute for Safe Medication Practice (ISMP)
- 46. HIGH ALERT MEDICATIONS(HAMS) • … those that are most likely to cause significant harm to the patient, even when used as intended. • … those medications with the highest percentage of, or potential for, medication errors and/or sentinel events and that carry a high risk for abuse, errors or other adverse outcomes. Institute for Healthcare Improvements (IHI) The Joint Commission (JCAHO)
- 47.
- 48. Guideline onsafe use of high alert medications
- 49. WHEN IT HAPPEN? Which one is less important? X Who? Why?
- 53. WHEN A MEDICATIONERROR OCCURS, ORGANIZATION WIDE SYSTEM WEAKNESSES ARE OFTEN IDENTIFIED IN : How information is collected and communicated, How colleagues interact, How patients and staff are educated, How the organizational culture and physical environment are managed, How staff is provided to carry out patient care functions, How staff learns about system errors and their causes, and How patients are safeguarded from harm.
- 54. Patient information Drug information Communication related to medications Drug labelling, packaging & nomenclature Drug standardization, storage & distribution Medication delivery device acquisition, use, and monitoring Environmental factors Staff competency & education Patient education Quality processes & risk management INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) HAS LISTED DOWN TEN KEY ELEMENTS THAT HAVE THE GREATEST INFLUENCE ON MEDICATION USE:
- 55. CONCLUSION Medication erroris common and is causing preventable human suffering and financial cost Remember that using medications to help patients is not a risk-free activity Interdisciplinary interactions go a long way toward preventing errors Know your responsibilities and work hard to make medication use safe for your patients
- 56.
- 57. THANK YOU Pusat MaklumatUbat @ Drug Information Centre, IKN Ext: 3434 or 3435 Unit Farmasi Klinikal Ext: 7114 or 7115
- 58.
Editor's Notes
- #2 Greetings! Assalamulaikum Salam sejantera Thank you for attending today talk, today I would like to talk about an important issues in patient care. Medication safety in an big issues but somehow smaller subset of medical errors. During this talk you will heard me using Medication Error, Medical Errors interchangeably.
- #3 Lets start our session with two case report. Case No 1 – Mr Smith, who is known case of kidney disease and on regular dialysis. Admitted to ICU after a dialysis session because of SOB. The next day, he complaint stomach upset hence his doctor prescribed antacid. The next day, his daughter came by to visit and found that his dad was unconscious and on a respirator. The nurse in-charged inform that, his dad had a code red. Upon asking the doctor who taking care of his dad – she found that the nurse administered the wrong medication. He said the packaging looked the same and he grabbed the wrong package. The nurse is wrongly given pancuronium which is muscle relaxant instead of antacid.
- #5 According to National Coordinating Council for Medication Error Reporting and Prevention, US; Medication error can be defined as any preventable event that cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.
- #6 At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.
- #7 Healthcare is nearly 10 years behind other industries in its efforts to reduce errors.
- #12 According to a publish paper in British Medical Journal 2016 by Makary and Daniel. Medical error is a third leading caused of death after heart disease and cancer which account for 251k death in US.
- #13 In Malaysia, we already seen a few case reported in local newspaper. This case become viral on social media. This however, just a gist of unreported medical error/negligence.
- #15 Prescribing- Doctor Transcribing – Nurse, previously Dispensing – Pharmacist Administering – Nurse-IP; Patient-OP Monitoring – Doctor.
- #16 What type of errors can occur during this process.
- #17 Medication safety is everyone’s responsibilities. Not only for pharmacist – its for all healthcare professional. There is for strategies to improve medication safety as placed by MOH Patient Safety Council of Malaysia. Reporting and learning from mistake. Dissemination of information – disseminate what the latest issues in patient safety. Guidelines – provide guidelines to reduced medication errors. Education and empowerment – educated all healthcare personal regarding medication errors and empower them to report and discuss about medication safety.
- #18 There is ways to prevent errors such as: Prescribing – electronic prescription – reduced risk of transcribing errors. Admixture and labeling – prepared by skill pharmacist technician and label to minimize error. Scanning – bar code scanning to minimized error. Check data and start – check patient information before serving medication. Documentation – document all process involved.
- #20 This form can be fill by anybody including patient. Not necessary must be fill by pharmacist.
- #22 In 2009, there is 2572 case of ME being reported to MERS. This report has double in 2010 and subsequently increased to 16897 cases in 2014. Which shown 8x increment from 2009.
- #23 The most common process in which the error occur are during prescribing – manual prescribing. Follow by dispensing and administration.
- #24 What are the contributing factors of ME? Staff factors New/In-experience. Lack of training Lack of empowerment Careless Not focus Work and environment Small area Noisy environment. Medication related Look a like sound a like Same medication, different strength. Task and technology Not femilar with technology.
- #25 In 2014- based on report form MERS. The main contributing factor of ME are staff factor followed by work environment, task and technology and medication related. Hmmm, medication related which account for 5% are not a big issues compared to others. So we are blaming the medication where our big problem are staff factors.
- #26 Staff factor are the main source of ME: Inexperienced personnel/Inadequate knowledge – are we train our staff enough? Did we under-train them? Distraction – did we give them conducive environment to work? Other main important contributing factor of ME are, sound alike medication. Failure to adhere to work procedure – for example need counter checking – did we properly counterchecking each and everyone? Heavy workload – understaff?. Peak hour when a lot of patient need to be entertained.
- #30 So we encourage to write full name rather than sing abbreviation.
- #33 Stick to 5B/5R rules. Always ask patient name before giving medication Give the right medication Give the right dose Using right route at a right time – warfarin give at 6pm. CCRT to give drugs before patient undergoes RT. Give patient insulin 30mins before meals.
- #37 Double checking the drug – that why we have check by column in the FISICIEN. Contact prescriber for any ambiguity List down the LASA medication – educate staff.
- #50 When it happen. It not who are important but why its happen are more important. We are not jugging or blaming who involved but we are more interested on why its happen and how to overcome its.
- #51 So when its happen, what you will do? REPORT! Do not hide errors caused latter on it will known eventually.
- #52 Some fact about what happen to WHO involved in ME.
- #53 So how to reduced harm??? Improve reporting and learning – discussed and learn regarding medication errors. Improve transfer of medicines and information between care setting – share information regarding patient safety, disseminate new info regarding new product especially change of product and dosage. Improve implementation of patient safety alerts – drug interaction alrets.
- #59 Check label for correct dose and instruction.