High risk medicines and prevention of Medication Errors

1. MEDICATION ERRORS &
HIGH ALERT
MEDICATIONS
Dr . UPPU JHANSI RANI (Pharm D)
Patient safety Pharmacovigilance Associate

2. Overview

3. Definition
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
healthcare professional, patient, or consumer according
to the National Coordinating Council for Medication
Error Reporting and Prevention.
Near Miss (Medication Error): The Medication error
that took place but captured before reaching the patient,
such events are termed as Near Miss errors.

4. Medication Errors
• Medication Errors cause at least one death
every day and injure approximately 1.3 million
people annually in the United States.

6. Prescription Error
• A prescribing error occurs at the time a prescriber
orders a drug for a specific patient.
• Errors may include:
 Incorrect drug selection for a patient
 Illegible hand writing
 Prescribing contraindicated drug
 Writing out list abbreviations

7. Dispensing Error
• Dispensing errors occur at any stage of the dispensing
process, from the receipt of the prescription in the
pharmacy to the supply of a dispensed medicine to a
patient.
• Incorrect drug, Incorrect strength, Incorrect dosage
form, miscalculation of doses.
Example: Dispensed Chlorpramazine instead of
Chlorpromide.

8. Look alike and Sound alike drugs

9.  Administration Error:
A drug administration error may be defined as the
discrepancy between the drug therapy received by the
patient and the drug therapy intended by prescriber.
• It involves wrong patient, wrong route of administration,
wrong time, wrong dose
• Example: Administration of Diclofenac IV instead of IM
 Transcription Error: Transcription is the process of
making an identical copy of prescription in the medical
records. Errors that occur during this process called
Transcription error.
 Indenting Error:
Errors that occur during the process of indenting .

10. SUB-TYPES OF MEDICATION ERRORS
Wrong Patient
Wrong Drug
Wrong time Error
Improper Dose Error
Wrong drug preparation Error
Wrong Administration technique Error

11. Factors that Contribute to Medication
Errors
 Excessive task demand
 Inadequate medication history
taking
 Inappropriate use of decimal points
 Use of abbreavtions(AZT)
 Lack of communication
 Lack of patient counseling

12. Factors that Contribute to Medication
Errors
 Environmental factors
 Look alike /sound alike drugs
 Lack of unit dose system
 Lack of independent check before
dispensing or administering the
medications
 Incomplete Knowledge of medicines
 Lack of drug availability

13. Barriers to Effective Error
Reporting
• Culture of Blameǃǃ

14. THE 6 R’s
• Right Drug
• Right Route
• Right Time
• Right Dose
• Right Patient
• Right Dosage Form

15. Medication Error Detection
• Directly observing medication administration
• Reviewing patient’s charts
• Attending medical rounds
• Analysing dose returned to the pharmacy
• Comparing medication administration records
with physician’s orders

16. Reporting Process
Whether paper or Electronic , a successful reporting system
should possess the following characteristics:
• Confidentiality: Patient, Reporter, Organization
• Easy to understand
• Requires minimal time to report
• Privileged:Allow using the data for quality improvement while
protecting from disclosure in potential legal proceedings

17. Reporting Process
Suggested Minimal fields for Medication Error data collection:
• Patient Information
• Date, time,Ward/dept
• Name of the medication prescribed
• Name of the medication administered
• Therapeutic classification of medication
• Route of administration
• Description of event
• type of error
• Patient outcome
• NCCMERP Categories

19. Root Cause Analysis
The Goal of RCA Process is to find out:
1. What happened?
2. Why did it happen?
3. What do you do to prevent it from happening
again?

20. Characteristics of an Effective Medication Error
Reporting System
 Organization goal should monitor both actual and potential
errors
 Should investigate the root cause of errors to prevent it.
 Encourage Voluntary Reporting of errors
 Provide confidentiality of reported information
 Provide confidentiality of reporter information
 Availability of both Electronic and paper ME reporting format
 Medication Errors should be reported and Documented

21. Process to prevent Medication Errors
1) Patient communication
2) Intra professional communication
3) Education and training
4) Electronic prescribing
5) Ensuring a safe dispensing procedure.
6) Recheck the prescription while transcribing, indenting
and administering the medications.

22. Actions that can be taken in
clinic Areas
 Risk Awareness-HIGH RISK DRUG
 Review Floor stock to reduce out of stock
 Use of Proper Labelling(Label HAM stickers on High
alert medication packages/Vials or Ampoules)
 LASA Medicines to be stored separately
 Ensure proper and correct programming of infusion
pump.
 Perform Independent double check

23. Definition: High alert medication
HAM Stickers should be labelled on the storage shelves,
Containers, Product package and loose vials
Labelling

25. Take a Home Message
• Medication Names should be written in
CAPITAL LETTER
• Abbreviations are not permitted
• Write clear orders
• Encourage Medication Error reporting