More people die annually from medication errors than from workplace injuries. An error in the prescribing, dispensing, administration of a drug irrespective of whether such errors lead to adverse consequences or not. In India, Medication Error is just a TERM and its significance is undervalued and remains unreported. Reported incidence of this iatrogenic disease related to medication error- tip of the iceberg. medication error can be visualized with the SWISS CHEESE MODEL OF SYSTEM accidents
Medication errors are described under prescription errors, transcription errors, administration errors. Based on the causes of errors the NCC MERP Index is formulated to categorize medication errors from Category A- I. Appropriate monitoring, good team communication, knowledgeable staff, RCA and policy on check of medication errors can reduce its incidence and make patient more safe.
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Causes, Incidence & Types of Medication Errors
1. Causes & Incidence of
Medication Error
DR. PRABHJOT SAINI BSN MSN PhD(N)
PROFESSOR & PRINCIPAL
SKSS COLLEGE OF NURSING
SARABHA, LUDHIANA, PUNJAB
email: psaini.dr@gmail.com , skssconsarabha@gmail.com
2.
3.
4. "To Err is Human“ - but not
at the cost of health of a
patient.
6. Medication Errors: Introduction
As many as 98,000 people die in any given year from medical errors that occur
in hospitals.
That's more than die from motor vehicle accidents, breast cancer, or AIDS.
Indeed, more people die annually from medication errors than from workplace
injuries.
7. The seriousness of medication error came to be known when
Institute of Medicine (US) stated in, “To Err is Human; Building a
Safer Health System,” that around 44,000 to 98,000 deaths in
America occurred as a result of medical errors.
The impact of medication error on patient's well-being is
unfathomable.
8.
9. Most of the medication errors do not cause any harm to the patient, but
there are some that cause unwarranted results, including
temporary or permanent harm to the patient's health and well-being
increased length of hospitalization
increase in cost of treatment
people losing faith in healthcare delivery system
and even deaths
10. A great need to break the silence that has surrounds medical errors and
their consequence.
Why these
mistakes
happen?
"How can we
learn from our
mistakes?"
11. How we define an error?
The word ERROR has drawn attention to "prevention"
According to Webster's New Collegiate Dictionary :
E.g. One can make An error of omission (failure to act correctly) Or An error of
commission (acted incorrectly)
Error is "an act that through ignorance, deficiency, or accident departs from or fails
to achieve what should be done is generally known as "the five rights": the right
Drug, right Dose, right Route, right Time, and right Patient.
12. Overview
What is medication error?
Incidence of medication errors
Causes of medication errors
Type of Medication errors
Factors contributing to Medication errors
Dangerous abbreviations
5 ‘High alert’ medications
Possible consequences of Medication errors
14. Medication error
An error in the prescribing, dispensing,
administration of a drug irrespective of whether
such errors lead to adverse consequences or not.
15. What is medication error?
The National Coordinating Council for Medication Error Reporting and Prevention
(NCCMERP) has defined medication error as
Thus, any medication error can be prevented before it may or may not cause harm to the
patient.
“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. These events may be related to professional practice, healthcare products,
procedures, and systems, including prescribing, order communication, product labeling,
packaging and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring, and use”.1
16. Medication error in
developed countries
is of PRIMARY
CONCERN
Medication Error is
just a TERM and its
significance is
undervalued.
Developed Countries Vs Developing
Countries
17. Medication error: Underreported
Medication errors are routinely encountered but remain
underreported.
Reporting is important to thoroughly examine their contributing
factors and to implement preventive actions so as to avoid them
in future from happening.
18. Medication error: why Underreported ?
Perception 1: it may be considered to be no one's fault (Haw, Stubbs, &
Dickens, 2014) or part of normal practice (Soydemir et al., 2016).
For instance, the standard time for administration of a once-a-day medication
may be 8:00 a.m. at a particular institution. A nurse administers a patient's
morning medications at 2:00 p.m. because the patient was away from the unit
for a procedure. No medical order indicated medications should be withheld
until after the procedure. Having a seemingly valid excuse for late
administration of the medication does not make this any less a medication
error. This error may go unreported because it is seen as a normal part of care.
19. Medication error: why Underreported
Perception 2: An error does not need to be reported if it does not
seem to cause harm. Nurses typically do not report near misses or
errors if there are no serious consequences (Hashemi, Nasrabadi,
& Asghari, 2012; Kim et al., 2014; Wagner, Damianakis, Pho, &
Tourangeay, 2013).
In the above example, the nurse may believe no harm was done because the
patient did not develop any obvious complications and so may not report
this late administration as an error.
20. Medication error: why Underreported
Perception 3: Lack of a reporting system at an institution or lack
of staff awareness that a system for reporting exists (Lederman,
Dreyfus, Matchan, Knott, & Milton, 2013; Soydemir et al., 2016).
Perception 4: Fear of consequences if a medical error is reported
(Almutary, & Lewis, 2012; Haw et al., 2014; Kagan & Barnoy, 2013; Yung, Yu,
Chu, Hou, & Tand, 2016).
21. Need to be reported
The Institute of Medicine supported the concept of a culture of
safety to encourage error reporting without fear of repercussion or
blame
Reason:
So that root cause of errors could be identified and prevention
measures instituted (Kohn et al., 2000).
23. Incidence of medication Errors
Interesting but horrifying facts:
More people in USA die in a given year as a result of medical
errors than from motor vehicle accidents , cancers or AIDS
Majority are medication errors
Indian study of paediatric intensive care unit reported 68.5% of
all errors were medication errors
24. Incidence
Reported incidence of this iatrogenic disease related to medication error-
tip of the iceberg
Difficult to determine
Few studies provide complete evaluation of errors
Different methods to detect errors
Various definitions of errors
Large volumes of medication dispensed
Annual prescriptions approx. 3.54 billion
Small % of 3.54 billion is still large number
25. Indian Scenario
Prof Jha reported 5.2 million medical errors take place in India annually.
The British Medical Journal quoted that India, like any other developing country,
is witnessing a lot of medical errors.
The main reason being that we do not have trained doctors and nurses to
measure the clinical outcomes.
26. Incidence
Harvard medical practice study found 19% of adverse event in
hospitalized patients R/T drug complications
Error rates in outpatient pharmacies reported ~12% and in-hospital
~1 error per patient per day
19% of all doses were not administered correctly
43% of errors were due to wrong time of administration
27. ~1.5 million people are harmed by medications each year
Up to 400,000 of adverse events considered preventable
Medication error studies reported different rates (underreported,
different tools used)
Errors before medications reaching patient are not reported.
29. Swiss Cheese Model
Need to identify and address the root causes of medication errors
Can be done through continuous quality improvement (CQI).
Medication error has multiple causes—a series of mistakes, oversights
or system failures that combine to create risk for a patient.
This type of medication error can be visualized with the SWISS CHEESE
MODEL OF SYSTEM accidents
32. What is Swiss Cheese Model?
Pictorial model for medication errors
Several slices of Swiss cheese, each represent a different layer of prescriber,
pharmacist, nurse & patient related defenses or safeguards
Each layer has holes that reflect the inherent weaknesses in that particular
safeguard.
Normally, if one hole is penetrated, another slice (or safeguard) stops an error in its
tracks.
But what if the holes suddenly lined up? Now it’s as though there are no safeguards at all.
34. Medication error : As per Occurrence
Near Miss:
A Near-miss is an unplanned event that did not result in injury, illness,
or damage but had that the potential to do so.
Did not result in patient harm, but could be categorized as near-miss
Medication incident/ Sentinal event:
An unexpected incident, related to system or process deficiencies, which
leads to death or major and enduring loss of function for a recipient of
healthcare services
36. Causes of Medication Errors
Calculation errors
Overload
Shortage of staff
Illegible Handwriting
Misinterpretation of Prescription
Human Errors
Inappropriate use of Abbreviations
Oral/Verbal orders
Look alike Sound alike drugs
Wrong dosage calculation
Improper use of zeroes and decimals
Careless prescription
Missing information
Drug Product characteristics
Drug preparation errors
Prescription labeling
Work environment & personnel issues
Lack of concentration
Double check not possible
37. 1. Calculation errors
Made by
Prescribers
Pharmacists
Technicians
Nurses
Pediatric population at risk- adult formulations be diluted/manipulated for peds
Personnel with multiple years of experience are just as likely to make
mathematical errors as inexperienced
43. 4. High Alert medication errors
Only written
orders
accepted
To be
checked for
adverse
reactions
44. 5. Prescribing errors
A clinically meaningful prescribing error occurs when, as a result of prescribing decision or
prescription writing process, there is an unintentional significant reduction in the treatment
being timely and effective and Increase in the risk of harm when compared with generally
accepted practice
It includes
Incorrect prescription #Missing information
Illegible handwriting # Use of apothecary system
Drug allergy not identified #Confusion regarding concentration of products
Irrational combinations
Out of list abbreviations
Verbal orders
45. Risk factors of prescribing errors
Work environment
Workload
Communication gap within team
Physical and mental well being
Lack of knowledge
Organizational factors(inadequate training)
Low perceived importance of prescribing
An absence of self awareness
46. 6. Wrong drug & wrong route
Drug-drug interaction
Warfarin prescribed to patient already on salicylate
Duplicative therapy
Atenolol ordered for patient already taking metoprolol
No indication
Cetrizine ordered for patient with fever
Wrong route
Order of betamethazone acetate suspension ordered to be given intravenously
47. 7.Dispensing error
Any unintended deviation among the dispensed drugs on comparison with the
written medical prescription or medication order is defined as dispensing error.
The range of dispensing errors even widens in the global scenario from 0.015 to
33.5%;
4 errors per day per 250 prescriptions filled
Over 51 million dispensing errors per year
48. Most prevalent dispensing errors
Similar names and packaging of drugs (look alike Sound alike)
Wrong dose, wrong drug, or wrong patient
Dispensing incorrect medication, dosage, strength or dosage form
Failure to identify drug interations or contraindications
Dosage miscalculations
Illegible handwriting,
Negligence by the pharmacists
Other: Judgmental errors, increased workload, lack of supporting staff, frequent
interruptions, and inadequate time to label the drugs and counsel the patients.
49. 8.Look alike Sound alike drugs
LASA drugs are medications that look or
sound similar to each other, either by their
generic name, or brand name.
They might have similar packaging, similar-
sounding names, or similar spellings.
54. 8.Illegible handwriting
The jokes about physicians and their sloppy handwriting are age-old.
But for some people it is not funny at all.
A misread prescription can lead to mistreatment and cause death.
Causes both prescription error and dispensing error
7,000 deaths annually are attributable to sloppy handwriting.
Recently in a programme on BBC : concluded that in Tamil Nadu, only
one in five doctors in rural areas writes legible prescriptions
60. 10.Drug concentration
Failure to include concentration in prescription can result in wrong
dose being dispensed
E.g.
•Amoxicillin suspension half tsp (2.5ml) TID
•Concentration??
1 amp or 1 vial or 1 cap UNCLEAR
Order for one vial of magnesium sulphate
•2ml vial (8mEq)
•20 ml vial (16mEq)
•10 ml vial of 50% concentration (40mEq)
62. 13. Communication failure
Failures during the process of patient management
Includes illegible handwriting, incomplete prescribing
order, vague instructions, prescription not recognized
& unknown prescriber
Common communication errors
Common errors include ‘g’ mistaken for ‘mg’
4 mistaken for ‘U’
Decimal point (.1 read as 1)
65. 15. Administration errors
Medication administration error (MAE) is defined as “any difference between what the
patient received or was supposed to receive and what the prescriber intended in the
original order”
It is risk areas of nursing practice while administering drugs
Majority of these errors involved either dose omissions (42%) or wrong time
administration (50 %)
MAE has a significant impact on morbidity, mortality, adverse drug event, and increased
length of hospital stay.
Thus, it increases costs to clinicians and healthcare systems
66. Administration error
Incorrect administration techniques
SC administered too deep
Instilling eye drops in wrong eye
IM injection at wrong site
It involves wrong patient, wrong route of adm.,
wrong drug, wrong dose, wrong method, wrong time.
67. Causes of administration errors
Lack of knowledge on drug
preparation, administration
Fail to check 5 R’s
Poor lighting
Wrong calculations to determine
correct dose
Noise and interruptions
69. 17. Transcription error
Transcription error is a process of making an identical copy of prescription in the
medical records. Error occurs during this process is known as transcription error.
An error that occurs during transcription of physicians order to the medication
administrative record (MAR)
E.g. orders transcribed to wrong patient, wrong drug, wrong dose, wrong schedule
Contributing factors:
Incomplete or illegible nurse handwriting
Use of abbreviations
Lack of familiarity with drug names
70. 18. Wrong time error
Wrong-time medication administration error (WTMAE) is a high risk to patient
safety.
It can result in severe harm, death or fatal consequences
Standardized administration time to be followed
Acceptable interval surrounding scheduled timing
WT errors are “dose administered 60 minutes before
or after scheduled time”
71. Example for wrong time administration
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During the
admission process in the early evening, the surgical resident restarted his maintenance
home medications, including oral dofetilide (an antiarrhythmic agent) taken every 12
hours. In the electronic health record, drugs ordered for "q12 hour" dosing are scheduled
for 6 AM and 6 PM by default. The overnight nurse saw that the morning dose was
scheduled to be given at 6 AM, but the patient was scheduled to leave for the operating
room before 6 AM, so she gave the dose early, at 4 AM. During his preoperative
assessment at around 6 AM, the patient was noted to have severe QTc prolongation on
his electrocardiogram, putting him at high risk for torsades de pointes, a sometimes fatal
arrhythmia. Considering the acute ECG changes (prior QTc intervals were normal), surgery
was canceled and the electrophysiology service was consulted.
72. 19.Deteriorated drug error
The drug to be given to patient has been unchecked or improperly
stored and deteriorated prematurely at appropriate place leading to
deteriorated drug error
Monitoring of expiry dates become essential
Refrigerated drugs being stored at room temperature or freezer
For example, administering insulin that has been frozen.
74. 21. Monitoring error
Failing to monitor the health status of the patient prior or post drug
administration
Inadequate drug therapy review
Ordering serum drug level tests and not reviewing test results
Prescribing antihypertensive drugs and failing to monitor blood pressure
Giving antipyretics and not assessing temperature
Administering Digoxin and not monitoring pulse/ heart rate
79. Summary
More people die annually from medication errors than from workplace injuries.
An error in the prescribing, dispensing, administration of a drug irrespective of whether such errors lead
to adverse consequences or not.
In India, Medication Error is just a TERM and its significance is undervalued and remains unreported
Reported incidence of this iatrogenic disease related to medication error- tip of the iceberg
medication error can be visualized with the SWISS CHEESE MODEL OF SYSTEM accidents
Medication errors are descibed under prescription errors, transcription errors, administration errors
Based on the causes of errors the NCC MERP Index is formulated to categorize medication errors from
Category A- I
Appropriate monitoring, good team communication, knowledgeable staff, RCA and policy on check of
medication errors can reduce its incidence and make patient more safe
80. References
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2010;22:507-18.
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Error Reporting and Prevention; 2015. (http://www.nccmerp.org/ about-medication-errors, accessed 19 September 2016).
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definitions and classification. Drug Saf. 2006;29:1011-22.
5. IMS Institute for Healthcare Informatics. The global use of medicines: outlook through 2016. Parsipanny, NJ: IMS; 2012.
6. Inch J, Watson MC, Anakwe-Umeh S. Patient versus healthcare professional spontaneous adverse drug reaction reporting: a systematic review. Drug Saf. 2012;35:807-18.
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8. Avery A, Barber N, Ghaleb M, Franklin BD, Armstrong S, Crowe S, et al. Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe study.
London: General Medical Council; 2012.
9. Claesson CB, Burman K, Nilsson JLG, Vinge E. Prescription errors detected by Swedish pharmacists. Int J Pharm Pract. 1995;3:151-6.
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11. Zavaleta-Bustos, Miriam, Lucila Isabel Castro-Pastrana, Ivette Reyes-Hernández, Maria Argelia López-Luna, and Isis Beatriz Bermúdez-Camps. Prescription Errors in a
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