Medication Safety: Prevent Errors & Adverse Events
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Medication saftey and error prevention
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Medication Safety: Prevent Errors & Adverse Events
- 1. Medication Safety & Error Prevention Shaukat Patel MS R.Ph. Clinical Pharmacist. Shore Medical Center
- 19. Philips J et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm. 2001 Oct 1;58(19):1835-41
- 20. Philips J et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm. 2001 Oct 1;58(19):1835-41
- 24. Handwriting
- 29. Written Rx Best Practices – Weights, Volumes, Measures
- 32. Written Rx Best Practices - Decimals
- 34. “ Look-Alike” Drugs Amiodarone Amrinone Amlodipine Amiloride Hydroxyzine Hydralazine Prednisone Prednisolone Celexa Celebrex
- 35. “ Sound-alike” Drugs Mellaril Elavil Paxil Taxol Prilosec Prozac Cerebyx Celebrex OxyContin Oxycodone
- 47. Allergy Screen
- 50. BPOC Bedside Device Wireless Laptop computer with a touch screen and bar code scanner
- 51. Barcode Technology Nurse barcode scans name tag Nurse barcode scans patient identification bracelet Patient MAR appears on bedside laptop Scheduled and prn meds are scanned Warnings/alerts are issued when indicated
- 55. ADE, ADR, & Medication Errors Adverse Drug Events
- 57. Consequences of ADEs Anaphylaxis – penicillin Deafness – gentimycin Pseudo. colitis –clindamycin Thrombocytopenia –heparin GI upset –erythromycin Urticaria – phenytoin Death $$$$ Permanent disability $$$$ Threat to Life $$$ Hospitalization $$$ ER visit $$$ Inconvenience $
- 60. Pharmacist: “The backbone” of Reporting Errors .
- 81. Thank You
Editor's Notes
- This chart shows the breakdown of medication error types for the 594 reports in which a patient died. Improper dose was the most common type, with a majority being overdoses (36.4%) Wrong drug (inadvertant administration of one drug product for another, e.g. potassium chloride injection instead of sodium chloride) Wrong route was the other major type of error (intrathecal instead of IV most common) Wrong patient fairly uncommon Other is comprised of wrong technique/rate/strength/dosage form/time, as well as monitoring and deteriorated drug errors (aggregate of many small things)
- In order to reduce the number of medication errors occurring, we need to recognize the behaviors that are causing the errors to occur. By far, human factors are the biggest cause. Includes: Performance deficits (gave drug IV instead of IM) Knowledge deficits (reasonable practice standards of education/CE) Dose miscalculations Preparation errors (wrong diluent, drug, active ingredient, or quantity) Incorrect selection of drug from computer/transcription errors Communication Order misinterpretation Oral/written miscommunication Name confusion Sound alike/look alike
- Something we’re all very familiar with (common question for RPh from techs “What does this say?) An’t go ONE day w/out saying this-preprnted/electronic froms rxs Can be tricky sometimes our assumptions are not correct Absolutely critical to double check on handwriting problems! Combinations of bad handwriting and similar drug names create perfect conditions for errors Example report of fatal bleeding in a patient prescribed Cogentin 0.5mg and given Coumadin 5 mg
- Errors of communication are an all too common cause of medication errors, particularly wrong drug and dose/frequency errors. Can be significantly reduced through double checks and following best practices for taking verbal orders and writing prescriptions
- This hospital order is difficult to interpret. Drug name looks like Plendil (wrong dose/frequency), or Zestril (right dose, wrong frequency), but may be something else based on the dose/directions.
- This is an order for HCTZ 50 mg PO daily; however, the lack of spacing between the drug name and strength could be misinterpreted as 250 mg of HCTZ per day
- Abbreviation misinterpretation is a frequent cause of mix-ups, and the ISMP/FDA are leading a campaign to eliminate the use of certain error-prone abbreviations Recommended that these abbreviations be written out QD/QOD/QID may be mistaken for one another if handwriting is not clear simply write out direction Do not abbreviate drug names (e.g. MS for “morphine sulfate” may be mistaken for magnesium sulfate) Eye/ear directions may look similar if handwriting is poor, leading to route of administration errors Source: http://www.nccmerp.org/dangerousAbbrev.html
- An order for regular insulin. As written, it could be interpreted as 6 U (six units) now, or as 60 units now. A 60 unit dose is improbable, but may be overlooked or not questioned, which could easily cause a patient’s glucose to bottom out
- Those of us that work on order forms know how prevalent these abbreviations still are Units of weights and measures also leave plenty of room for error U may be mistaken for a 0 or 6 IU may be mistaken for IV, leading to fatal IV administration errors µg may be misread as milligram instead of microgram, a thousandfold dose error Apothecary units are often unfamiliar to practitioners Use of fractions of a grain (e.g. 1/100 grain) can lead to fraction errors or conversions to metric Use of symbols for teaspoon/tablespoon/ounce can be confusing
- Decimal errors are of particular importance because an error in a decimal can result in a ten or more-fold dose error! The problem with decimals is that they always leave a space for error if missed. Avoid whenever possible. Always place a zero in FRONT of a decimal to avoid misinterpretation (Risperdal .5 may be read as “5 mg”, a ten fold overdose) Avoid trailing zeros whenever possible
- Seeing it in actual writing makes it easier to recall how easily decimal errors can occur. Simply missing the decimal would expose a patient to a ten-fold overdose of colchicine or levothyroxine, both of which would have serious consequences
- A number of drugs have names that look similar enough to cause confusion These names may be misread when in a hurry or not paying close attention to work Compounding the problem is the fact that some of these drugs have similar strengths and indications These are just a few examples. A complete list is available from the ISMPs website Not JUST names but PACKAGING too
- Just as look alike drugs can lead to errors in prescription reading and dispensing, sound alike drugs are a pitfall of verbal orders for medication
- Verbal prescription orders add an extra risk of error in several ways Communication issues foreign/local accents or dialects may be misunderstood Background noise in the pharmacy/MD office, as well as interruptions Unfamiliarity with the drug name, terminology for directions may generate an error Despite convenience of verbal orders, they do add an additional step for an error to be made, a risk which must be mitigated
- So what behaviors can we change to reduce the number of verbal order errors that occur? Having a set read-back procedure is a easy way to immediately double check what was just ordered Read back patient name, DOB, drug name, strength, dose, frequency, quantity Double checking protects everyone patients from drug errors, and health care professionals/hospitals from liability resulting from errors
- Study published in 2010 NEJM this year found that the use of bar coding technology coupled with electronic medication administration records (eMARs) significantly reduced the rate of error in the hospital setting Technology cross-checks bar codes on a patient’s wrist with the drug about to be administered to ensure the correct patient, drug, strength/dose, and time.
- This diagram gives a visual of the relationship between ADE, adverse drug reactions, and medication errors for perspective. The intent is to illustrate several points: Not all MEs result in ADE, and fewer result in ADR (only about 1% result in ADE) Approximately 25% of ADEs are caused by medication errors, and are often serious in nature That the small percent of ADEs resulting from errors costs the patients and the healthcare system such an enormous amount drives the need to reduce errors wherever possible Source: Nebecker et al. Clarifying Adverse Drug Events. Ann Intern Med 2004; 140: 795-801.
- This slide is intended to visually highlight the impact of ADEs across the spectrum of severity Minor ADEs may cause simple inconveniences like GI upset or drowsiness Moderate ADEs may require medical attention or hospitalization, leading to greater financial burdens Severe ADEs lead to serious consequences, which in addition to creating a financial burden for patients, also tend to greatly impact a patients quality of life, particularly if full recovery is impossible (e.g. aminoglycoside hearing loss)
- Process at Shore. Helps ID problems
- These are some non-punitive approaches to error reduction By fostering an environment where practitioners do not need to fear being publicly or professionally “crucified”, we can encourage the reporting of errors and provide constructive feedback on how to make changes from the blunt end. Community/media education about error prevention efforts is important People need to know the healthcare field is made of other people who genuinely care about their safety The media tends to sensationalize medication errors, so making knowledge of error prevention efforts public may be a good way to mitigate this
- It is important to focus on the human factors involved in medication errors due to the inherent limitations of the human brain Past research has shown us that humans can store at the most around 7 items in short term memory, which in reality may be a generous limit Number is limited in practice due to other things pulling our attention away This has happened to all of us focused on multiple things and end up forgetting something important Humans have a limited capacity to remember things, as well as to observe events going on around us We aren’t very good at estimating probability, possibly due to other factors that influence our predictions of events (e.g. whether we want an event to happen or not or whether we have all the details)
- So how do we reduce human error in the health care system? We use computers to perform tasks that are tedious, or which may involve significant human error. Computers have their own limitations, chief of which is that they are only as good as the person using them computers don’t make mistakes, the people using them do Computers are unable (right now) to show common sense or true clinical judgement They can only generate results based on set parameters (for example, listing all possible drug interactions for a given drug pair, rather than decided which ones to question and which ones to let go)
- Simply double checking key information while entering a script can prevent errors
- Coach your staff into the habit of multi-checking everything Checks of
- Route of administration errors carry a greater potential to cause fatal medication errors due to inadvertent IV/IT administration Constant vigilance and questioning is required to prevent Labeling of products not intended for a particular route of administration is critical Examples Nonsterile/non-pH balanced ear preps used in the eye can cause irritation and other problems FDA reports of deaths linked to accidental administration of nimodipine oral capsules intravenously (nimodipine is used for control of vasospasm s/p cerebral hemorrhage) Liquid in capsule withdrawn using IV syringe and 18 gauge needle for use with nasogastric tube syringe not labeled and later given IV push, leading to death Reports of deaths when vinca alkaloids used for chemotherapy were given intrathecally instead of IV
- Find a way to differentiate products that look similar Often an issue with a generic brand that uses identical packaging for many drugs (Mylan in particular) “ Tall Boy” lettering style – highlights portions of drug name that are dissimilar Be creative in coming up with a way to effectively differentiate between similar drug products. Shelf separators should be a part of any system, as they prevent drugs/strengths from getting mixed together