Learn from medication errors

1. Nazmi Liana Azmi
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2. What to do when a medication error
happens?
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3. Rule no. 1
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4. Rule
no. 2
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5. Rule no. 3
Fill up medication
error form
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6. Rule no. 4
Fill up Incident
Reporting Form
(certain cases
especially for
medication errors
which cause harm)
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7. Remember!
and
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8. Why?
Through these
errors we can
learn
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9. RCA at Pharmacy department in
2020
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11. WRONGLY DISPENSED
TAB. LAMOTRIGINE 100MG
INSTEAD OF
TAB. LAMOTRIGINE 5MG
ME CATEGORY F
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12. Error outcome category
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13. ■ Patient, 3-year old boy, diagnosed with congenital refractory
seizure was prescribed with up-titration regime of Tab.
Lamotrigine, starting from the dose of 15mg OM, 10mg ON on
11/3/2020.
■ However, his prescription was wrongly filled and dispensed with
Tab. Lamotrigine 100mg instead of Tab. Lamotrigine 5mg
(chewable). At home, the mother used the remaining correct
medication (Tab. Lamotrigine 5mg) from the previous
prescription and gave a dose of 300mg (3 tablets of 100mg) on
16/3/2020.
■ Patient was lethargic, drowsy and vomitted 4 times, rushed to
KK Perol before admitted to HRPZ II.
WRONGLY DISPENSED TAB. LAMOTRIGINE 100MG
INSTEAD OF TAB. LAMOTRIGINE 5MG
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14. WRONGLY DISPENSED TAB. LAMOTRIGINE 100MG
INSTEAD OF TAB. LAMOTRIGINE 5MG
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15. CHRONOLOGY
The mother handed prescription at counter
Pharmacy assistant entered the data and printed the labels
Pharmacist A wrongly filledTab. Lamotrigine 100mg instead of
Tab. Lamotrigine 5mg (chewable)
Pharmacist B labelled and counter-checked
the medications at the same time
Pharmacist called the patient but the mother did not turn up at the
counter
The mother came to collect medications from PRP at counter 7
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16. WRONGLY
DISPENSED
TAB.
LAMOTRIGINE
100MG
INSTEAD OF
TAB.
LAMOTRIGINE
5MG
TASK & TECHNOLOGY
FACTORS
1. Medication with multiple
strengths
2. Similar packaging size
TEAM FACTORS
1. Lack of supervision
MANAGEMENT &
ORGANISATIONAL
FACTORS
1. Improving existing
policy
PATIENT FACTORS
1. Complexity of treatment
regime
INDIVIDUAL STAFF
FACTORS
1. Lack of competence
2. Noncompliance to
policy
WORK/CARE
ENVIROMENT FACTORS
1. Peak hour
2. Congested storage area
3. No precaution labels
EXTERNAL FACTORS
1. Confusing
prescription
2 3
4 5 6 7
16
1

17. ■ Improving existing policy
■ The existing work flow was revised
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MANAGEMENT &
ORGANISATIONAL
FACTORS
1. Improving existing
policy1

18. ■ PRP should always be supervised and should not be left to
dispense alone
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TEAM FACTORS
1.Lack of supervision
2

19. ■ Tab. Lamotrigine had 4
strengths: 5mg, 25mg, 50mg
and 100mg.
■ Tab. Lamotrigine 5mg and
100mg, they even had similar
packaging size
19
3
TASK & TECHNOLOGY
FACTORS
1.Medication with multiple
strengths
2.Similar packaging size

20. ■ Doctor can help to reduce
error by writing the
prescription in the simplest
manner possible
■ Tab. Lamotrigine alone was
prescribed 6 times with
different doses, unclear
instructions minus the
durations in the notes column
20
4
EXTERNAL FACTORS
1.Confusing prescription

21. ■ The incidence happened during
clinic day at peak hour.
■ The storage area was also
congested with so many
medications were cramped into
the compartments
■ The uses of precaution labels are
important to minimize the risk
of medication error.
21
5
WORK/CARE
ENVIROMENT FACTORS
1.Peak hour
2.Congested storage area
3.No precaution labels

22. ■ Lack of competence - junior
FRP, senior pharmacist but
unfamiliar with the drugs
(other specialization)
■ Noncompliance to policy - no
signature at the dispensing
column which was a
noncompliance to protocol.
22
6
INDIVIDUAL STAFF
FACTORS
1.Lack of competence
2.Noncompliance to policy

23. ■ Patient was prescribed with
multiple drugs for
congenital refractory
seizures.
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7
PATIENT FACTORS
1.Complexity of treatment
regime

24. ■ Congested storage area
■ No precaution labels
■ Non-compliance to
policy
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No.
Contributing Factors/ Root
Causes
Description of Action Plan
1.
Storage area was congested
with so many medications
were cramped into each
compartments
To organize the arrangement of
medications by reviewing the allocation
of medications. Drug with multiple
strengths and LASA medications also
should be set apart from each other
2.
No precaution labels
(existing labels are exactly
the same for all medications)
To label medications usingTALL man
lettering and additional warning signs to
highlight LASA items as well as using
colour-codes to differentiate
pharmacological classes
3. Noncompliance to policy
To emphasize on triangle check (check
actual medications against the labels
and prescription) in order to standardize
counter-checking.
To revise existing policy in order to
review the burden on each process.

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