This document provides an overview of medication safety and medication errors. It defines key terms like medical error, adverse drug events, and near misses. It discusses the scale of medication errors, estimating they occur in 5-14% of doses dispensed and 1 in 100 result in an adverse drug event. Preventable medical errors occur in over 3 million hospital admissions and outpatient visits annually in the US, resulting in over 7,000 deaths each year. Factors that contribute to medication errors include complex medication regimens and lack of communication between healthcare providers. Strategies to improve safety include using generic drug names, tailoring prescriptions to each patient, thorough medication histories, awareness of high-risk medications, and encouraging patient involvement.

1. Medication error

2. © 2008 Board of Trustees of U of IL
“The science and technologies involved in healthcare
-- the knowledge, skills, care interventions, devices and
drugs -- have advanced more rapidly than our ability to
deliver them safely, effectively, and efficiently”
IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st
Century.
Medication use has become increasingly complex
in recent times

3. Objectives
• To provide an overview of medication safety
• Understand the scale of medicational errors
• Identify factors that contribute to medicational errors
• Learn how to make medication use safer

4. Medical error
• Medical error: an act of omission or commission in
planning and execution that contributes or could
contribute to an unintended result.
• This definition of medical error includes explicitly the
key domains of error causation (omission and
commission, planning and execution), whether
adverse outcomes occur or not.
• Patient harm from medical error can occur at
individual or system level.
Ethan D Grober, John MA Bohmen. Defining medical error. Can J Surg 48(1) 2005 Feb

5. How dangerous is health care?
• Less than one death per 100,000 encounters
• Nuclear power
• European railroads
• Scheduled airline
• One death in < 100,000 but >1000 encounters
• Driving
• Chemical manufacturing
• More than one death per 1000 encounters
• Bungee jumping
• Mountain climbing
• Health care (hospitalization)

6. Medication errors
• Medication errors: any mistake occurring in the
medication use process, regard less of whether an
injury occurred or whether the potential for injury
was present
• Studies- ME occurred in at some point in medicational
process in 5-14% of doses dispensed*
• Approximately 1 in 100 medication errors result in an
ADE, while 5 in 100 have a potential to do so
*Luigi Brunetti, Don-Churi Suh. Jour of Hospital Administration Dec 2012:Vol 1, No 2

7. Adverse drug events (ADEs)
• ADEs are defined as any injuries resulting from medication use,
including physical harm, mental harm, or loss of function.
• ADEs, compared to medication errors are a more direct measure of
patient harm
• Adverse drug events accounts for 19% of all injuries caused by
medical care

8. Adverse drug events (ADEs)
• Preventable ADEs are ADEs that can be avoided. At least 1/4th of
ADEs are preventable
• Adverse drug reactions are ADEs non preventable ADEs and occur
due to pharmacological properties of the drug
• Near miss errors (potential ADEs) pose a significant risk, but do not
cause harm to a patient. Potential ADEs include errors that are
intercepted before patient is effected

9. 9
Definitions
Near Misses
ADEs
Medication Errors

11. Scope of medication errors: USA
• Serious preventable medical
errors occur in
• 3.8 million inpatient admissions 1
• 3.3 million outpatient visits 2
• Mortality from preventable
medication errors
• 7000 deaths each year 3
1.Massachusetts Technology Colloboration (MIT) and NEHI 2008. Saving lives, saving money
2.Center for information Technology (CITL) 2011
3.IOM.To err is human. Building a safer health system. Washington DC 1999

12. Annual cost of preventable medication errors
by setting (US)
1. NEHI 2008
2. CITL 2007
3. Burton MM, Hope C et al.
1
2,3

13. 13

14. Types and Setting of Preventable MEs
• Dosing errors makes up 37%
• Drug allergies/ harmful drug
interactions account for 11%
• Approximately 100 undetected
dispensing errors can occur each
day

15. NCC MERP index for categorizing medical
errors
2001 National Coordinating Council for Medical Error Reduction and Prevention

17. Stages - Medication Errors

18. 18
Comparisons of Adult and Pediatric Inpatients
Pediatrics Adults**
Orders reviewed 10,778 10,070
Medication errors 616 (5.7%) 530 (5.3%)
Near Misses 115 (1.1%) 35 (0.35%) *
ADEs 26 (0.24%) 25 (0.25%)
Preventable ADEs 5 (0.05%) 5 (0.05%)
*p value <0.05
**Study performed at Brigham and Women’s Hospital
Kaushal et al, JAMA 2001

19. Near Misses in the NICU per 100 orders
2.8
1.3
0.77
0.35
0
0.5
1
1.5
2
2.5
3
NICU PICU Med/Surg Adult
*
*
* P<0.001
JAMA 2001;285;2114-20
*
ICU

20. Error reduction
No one makes an error on purpose
Lucian
Leape
Every one makes dumb mistakes every day
No one admits an error if you punish them for it

21. Error reductions: system approach
• Culture of Safety
• Non-punitive systems
• Multidisciplinary error prevention
• Avoid fatigue
• Minimize distractions
• Independent double checks
• 2nd checker will detect ~ 90% of
errors made by first checker
• Facilitate patient engagement
• On going education
• HIT

22. Multidisciplinary error prevention: Avoid
fragmentation of care
• Improved communication among physicians, nurses and pharmacists
prevented 85% of preventable serious medicational errors 1
• Including a pharmacist on routine medical rounds led to a 78%
reduction in medical errors 2
• Adding a pharmacist to a physician rounds team in an ICU led to
annual savings of $270,000 2,3
• Dedicated care – doctors and nurses
• My experience ---
1. Fortescue et al. Prioritizing statgies for preventing Mes and ADEs in pediatric inpatients. Pediatrics 2003. 111: 722-729
2. Kukukarsalan SN et al. Pharmacists on rounding teams prevent preventable ADEs.
Arch Int Med 2003. 163(17): 2014-2018
3. Leapp LL et al. Pharmacist participation on physician rounds and ADEs in ICU. JAMA 1999. 282(3):267-270

23. What can we do to make medication use
safer?
• Use generic names. Look alike, sound alike medicines
• Tailor prescribing for each patient
• Learn and practice thorough medication history taking
• Know the high-risk medications and take precautions
• Know the medications you prescribe well
• Use memory aids
• Communicate clearly
• Develop checking habits
• Encourage patients to be actively involved
• Report and learn from errors

24. Generic names: Look-a-like and sound-a-like
medications
• Clinician’s Pocket Drug
Reference 2015
• Rapid information on
over 1400 look-a-like
and sound-a-like
medications, arranged
alphabetically

26. Tailor prescribing for individual patient
Consider:
• allergies
• co-morbidities (especially liver and renal impairment)
• other medication
• pregnancy and breastfeeding
• size of patient

27. Medication history taking

28. Medication history taking
• Include name, dose, route, frequency, duration of every
drug
• Enquire about recently ceased medications
• Ask about over-the-counter medications, dietary
supplements and alternative medicines
• Make sure what patient actually takes, matches your list:
• be particularly careful across transitions of care
• Look up any medications you are unfamiliar with
• Consider drug interactions, medications that can be ceased
and medications that may be causing side-effects
• Always include allergy history

29. Medication history taking
• A 74-year-old man sees a doctor for treatment of new onset stable
angina
• The doctor has not met this patient before and takes a full past
history and medication history
• He discovers the patient has been healthy and only takes medication
for headaches, name of which the patient cannot recall
• The doctor assumes it is an analgesic that the patient takes whenever
he develops a headache

30. Medication history taking
• Medication is actually a beta-blocker that he takes every day for
migraine; this medication was prescribed by a different doctor
• Patient is prescribed aspirin and another beta-blocker for the angina
• After commencing the new medication, the patient develops
bradycardia and postural hypotension
• Unfortunately the patient has a fall three days later due to dizziness
on standing; he fractures his hip in the fall

31. Which medications are high risk?
• Narrow therapeutic window
• Multiple interactions with other medications
• Potent medications
• Complex dosage and monitoring schedules
• Some examples:
• oral anticoagulants
• Insulin
• chemotherapeutic agents
• neuromuscular blocking agents
• aminoglycoside
• intravenous potassium
• Cardiovascular medications

32. Avoiding ambiguous nomenclature
• Avoid trailing zeros
• e.g. write 1 not 1.0
• Use leading zeros
• e.g. write 0.1 not .1
• Know accepted local terminology
• Write neatly, print if necessary

33. Remember 5 Rs
• Right drug
• Right dose
• Right route
• Right time
• Right patient

34. Ten rights (‘Rs’) for medication
• 5 Rs +
• Right documentation
• Right medication history and assessment
• Right drug-drug interaction and evaluation
• Right education and information to patient
• Right to refuse

35. Some examples from my experience
• Administration of 10 mg of morphine to new born baby, though it was
prescribed to the mother
• 5-ml of KCl given IV directly - 2 incidents
• Baby on high dose ionotrope in ICU goes in shock because
extravasation of fluid was detected late
• Wrong calculation of insulin dose in NICU.(X ten times)
• 10 times required dose of epinephrine given IV instead of IM for
anaphylaxis

36. NSW Examples - Medication Errors
Aspirin and clopidogrel
ceased in ICU and not
recommenced when
patient transferred to
ward
Patient suffered
sudden cardiac
arrest resulting in
death
May have
contributed to
patient’s
death
Patient prescribed
ramipril 1.25mg daily,
medication chart was
rewritten as ramipril
12.5mg daily
Patient suffered pre-
syncopal episode,
was transferred to
HDU and required
noradrenaline
Caused
temporary
harm and
required
intervention
Patient initiated on
new cardiac
medication,
discharged with no
summary or medicine
Patient became
acutely unwell and
was re-admitted
Caused
temporary
harm and
required
intervention
The degree of harm experienced by patients can vary depending on the type of error
and the medication involved.

37. Know the medication you
prescribe well
• Do some homework on every medication you prescribe
• Suggested framework
• pharmacology
• Indications
• Contraindications
• side-effects
• special precautions
• dose and administration
• regimen

38. Use memory aids
• Formulary, protocols, textbooks
• Personal digital assistant
• Computer programs, computerized prescribing
• Free up your brain for problem solving rather than remembering facts
and figures that can be stored elsewhere
• Looking things up if unsure is a marker of safe practice, not
incompetence!

39. Develop checking habits
• When prescribing a medication
• When administering medication:
• check for allergies
• check the 6 Rs
• Be careful about look alike-sound alike medicines
• Remember computerized systems still require checking
• Always check and it will become a habit!

40. Develop checking habits
• Some useful maxims …
• Un labelled medications belong in the bin
• Never administer a medication unless you are 100% sure you know
what it is
• Practice makes perfect
• so start your checking habits now

41. Patient safety
• Computerized Physician Order Entry (CPOE)
• Reduces serious medication errors by 81%
• Electronic Medication Administration Record (eMAR)
• Bar coding
• 51% reductions in medical errors
• Smart pumps
• Pharmacist interventions
• Daily medication review
• Participation on rounds
• Medication reconciliation – identifies medication discrepancies during transition and
discharge

42. 42
Conclusion
“Our systems are too complex to expect
merely extraordinary people to perform
perfectly 100% of the time. We as leaders
have a responsibility to put in place
systems to support safe practice.”
James Conway, former VP and COO Dana-Farber Cancer Institute

43. Questions?

44. What causes errors?

45. 45
Stages
Administering
Ordering
Dispensing
Transmitting
Administering
Ordering
Dispensing
Transmitting
Preventable ADEs Near Misses

46. M. Makery, Matin Daniel. Medical error-3rd leading cause of death in US. BMJ 2016;353

47. ⦿ “ an event or circumstance involving drug therapy that
actually or potentially interferes with desired health
outcomes” (PCNE, 1999).
⦿ MRP occurs when a patient experiences or is liable to
experience either a disease or symptom having a definite
or assumed association with drug therapy (Linda et al.,
1990).

48. Access to treatment
1. Untreated indication
Effectiveness
2. Improper drug selection
4. Inappropriate use by patient
5. Overdosage
Safety
8. Medication without indication

49. • Inappropriate use by the patient
• Adverse drug reactions
• Lack of knowledge about disease and drug
therapy

50. ⦿ Prescribing
⦿ Dispensing
⦿ Drug use process

51. Medication
Related
problems
(MRPs)
Patient
behaviors
problem
Physician
prescribing
problem
Real MRPs
Manifest and
influencing
outcomes
Avoidable
problem
Potential MRPs
Not manifest but
possibly
influencing
outcomes
Avoidable
problem
Unavoidabl
e problem
Pharmacy
dispensing
problem
Unavoidable
problem

52. PCNE (Pharmaceutical Care Network Europe)
• 4 primary domains for problems
• 8 primary domains for causes
• 5 primary domains for Interventions
• 4 primary domains for outcome of intervention

53. PCNE classification of MRPs

54. Pharmacists can detect and either prevent or resolve many of
these MRPs.
Pharmaceutical Care focuses in identification, solving and
prevention of MPRs.
Pharmaceutical care (Hepler and Strand, 1984)
“responsible provision of drug therapy for the purpose of
achieving specific outcomes that improve a patient's
quality of life”

55. Pharmaceutical care involves three major functions:
(1) Identifying potential and actual MRPs
(2) resolving actual drug-related MRPs
(3) preventing potential MRPs

56. ⦿Data Collection
• What is the information we have to interpret?
• the patient as an information source
• gaining information from other sources
•caregiver
•physician
•other provider
•chart
Problems may be actual (present) or potential (occur in the
future if no intervention)

57. ⦿Evaluation of the patient data
• Must evaluate data to determine if problem exists
evaluation questions relate to the drug therapy problems
Do any of the problems exists?
⦿
Problem can be:
• untreated indication
• wrong drug being taken
• too little of the correct drug
• too much of the correct drug
• adverse drug reaction present
• drug-drug/food/lab interaction
• not receiving the prescribed drug
• use without valid indication

58. ⦿Evaluation of the patient data - Problem identification
▪ Does the patient have a condition or symptoms that need
to be treated?
• What are the patient’s symptoms, or diagnosed conditions?
• Can you treat the patient or does he or she need to be referred
to another health professional?
▪ If the patient has a legitimate need to be treated for
conditions or symptoms, is the treatment he or she is getting
the most effective and safe?
▪ What are the appropriate treatments for this condition?
•What patient factors (dx, allergy, prev. patient responses,
pharmacokinetic variables, social conditions, etc.) are present
that may affect agent choice?

59. What other medication is the patient taking and how might this
affect agent choice?
What has the patient response been to the current therapy?
What has the patient response been to previous therapies?
If the patient is on the correct drug is he or she receiving too
little of this drug?
What dose of the drug is the patient really getting?
What are the acceptable doses of this drug?
How do we titrate this drug for this condition?
What are the appropriate monitoring parameters for this
condition and have they been used to justify a higher dose?
Is the patient likely to tolerate a higher dose?
What patient factors (diagnoses, allergies, previous patient
responses, pharmacokinetic variables, social conditions, etc.) are
present that may justify an increased dose?
What other medication is the patient taking and how might this
cause a need for an increased dose?

60. Resolution of actual or prevention of potential MRPs is the
second component in providing pharmaceutical care to a patient.
Determining desired therapeutic outcomes (what is the goal)
o need to know where we are going therapeutically
o commonly not well defined by physician
–use of your professional skills
–use knowledge gained (pharmacotherapy)
o should have as part of the goal, one of the four positive
outcomes of drug therapy
o set definitive, measurable end-point if possible

61. ⦿Evaluation of therapeutic alternatives (what are the options)
• list all possible alternatives
–do not dismiss any on first thought
–include more than you can initially remember
• be sure to include non-pharmacologic therapy as alternatives
• include “do nothing” as an alternative

62. Correction of drug related problems - Best alternative
drug regimen recommendation and individualization (what is the
best option, and how to implement)
• what is best for this patient at this time
• drug, dose, route and dosage form, regimen, duration of
therapy
• develop action plan to implement recommendations
• agree with patient/other provider on plan
• implement that plan
–what will be done, how will it be done

63. Correction of drug related problems – Monitoring
Design and implement monitoring plan (what is done to see if the
option worked)
What needs to be followed up?
–did the recommendation work?
–were there adverse consequences to the recommendation
When does it need to be followed up?
• schedule a time for follow-up
–when is likely therapeutic effect?
–when would adverse effects be likely?
• determine a method of follow-up
• agree with patient on time and method
Implement the monitoring plan
Every patient should be followed up until he or she is no longer
a responsibility of your practice

64. Documentation
• patient name
• medical problem list
• medication list
• allergies
• drug-related problem list
• problem-oriented notes

65. ⦿ Prescriptions should always be reviewed by a pharmacist
⦿ Patient profiles should be current and complete
⦿ Design of the dispensing area is imp
⦿ Product inventory should be arranged to help
differentiate medications
⦿ Limiting assess to high alert medication, beware of look
alike sound alike drugs
⦿ Be careful with zeros and abbreviation
⦿ A series of checks should be established
⦿ Independent double check orders both on calculation &
preparation
⦿ Labels must be read at least three times

66. ⦿ Pharmacists must counsel patients
Assess patient’s level of comprehension
See if patient seems able to properly read directions - Do not
assume
Ask the patient leading questions
Provide education sheets
⦿ Dispense medication using unit-dose, ready to
administration form whenever possible
⦿ Patient name, generic drug name, patient specific dose
on all labels

67. Clarify confusing orders
IF YOU DON’T KNOW, ASK!!!!
⦿ There are no stupid questions
⦿ If something seems wrong, it just might be
⦿ Ask many questions to clarify your concern
⦿ Be sure you are asking the question clearly and the
responder understands the question
⦿ Always think five RIGHT’s rule
The RIGHT
▪ person
▪ dose
▪ medication
▪ frequency
▪ route

68. ⦿ Read back
⦿ Spell the name of medication
⦿ Spell out numbers like 17 vs. 70
⦿ Make sure you have all needed information
⦿ Ask for indication
⦿ Do not use unapproved abbreviations
⦿ Do not hesitate to call back for clarification

69. Develop protocols for verbal orders to assure that:
Ordering/prescribing practitioners must be identified
Patients must be clearly identified
Verbal orders must be clear and concise
Verbal orders from on-site practitioner are taken only in
emergencies
No verbal orders are taken for chemotherapy
All verbal orders are repeated for verification

70. ⦿ MRPS and very common which is preventing achievement of
desirable therapeutic outcomes.
⦿ Pharmacists must actively participate and intervene to
reduce the incidence of MRPs despite the discouraging
behavior of other health care professionals.
⦿ Pharmacist effectively can identify, solve and prevent
clinically significant MRPs.
⦿ A proactive rather than a reactive approach seems prudent
for obtaining the greatest benefit from interventions.
⦿ We should keep our clinical knowledge up-to-date for
making interventions to reduce the incidence of MRPs.

71. ⦿ Bindoff, I. K., Peterson, G. M., Tenni, P. C. and Williams, M. (2012) A clinical
knowledge measurement tool to assess the ability of communi- ty pharmacists to
detect drug-related problems. Int. J. Pharm Pract, Volume 20, Pages 238-48.
⦿ Foppe Van Mil. Drug-related problems: a cornerstone for pharmaceutical care.
Journal of the Malta College of Pharmacy. 2005; 10: 5-8.
⦿ Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am
J Hosp Pharm. 1990; 47:533–43.
⦿ Linda M. S., Peter C.M., Robert J. C. et al. Drug related problems: Their structure
and function. DCIP Annals of Pharmacotherapy. 1990;24:1093-97.
⦿ National Coordinating Council for medication error reporting and prevention (NCC
MERP). About Medication Errors. [Cited 17-04-05]. Available from http://
www.nccmerp.org/about mederrors.htm.
⦿ Ulrika, G. (2012) Effects of Clinical Pharmacists Interventions on Drug- related
Hospitalization and appropriateness of Prescribing in Elderly patients. Digitala
Vetenskapliga Arkivet, Volume 154, Page 58.
⦿ Van Mil JWF, Schulz M, Tromp TF. Pharmaceutical care, European developments in
concepts, implementation, teaching, and research; a review. Pharm. World Sci.
2004;26:303-11.

72. A case of unknown problem--
Compensation

73. A case of medical error--Compensation

74. A case of medical error ??
—Ayurved – Injections?

75. Patient’s can die
But is the hospital always to blame?

76. Violence against doctors
increased by many folds

77. Hospitals resorting to
new practices
Is this helpful-NO?

78. Medication errors – and their roots
• Medication errors may arise from:
• poor communication; (short timed patient-doctor interaction)
• misinterpreted handwriting;
• drug name confusion;
• confusing drug labels,
• labeling, and packaging;
• lack of employee knowledge; and
• lack of patient understanding about a drug's directions.
• But it's important to recognize that such errors are due to multiple
factors in a complex medical system

79. Environment as cause of medication errors
Some environment are more prone to making medication
errors:
• ineffective communication with patients
• ineffective communication with other healthcare providers
• emphasis on volume over service quality
• fatigued staff
• inadequate staffing
• frequent interruptions and distractions
• poor physician handwriting
• stress
• improper technician training
• disorganized work flow

80. Doctors resorting to
new practices
Is this helpful-NO?

84. LASA drugs
1. LASA drugs -Similar brand names, different generic composition
(Category I)
2. LASA drugs- Similar brand names, same generic composition (Category
II)
3. LASA drugs- Similar brand names with additional letter (Category III)
4. LASA drugs- Similar brand names of the Antibiotics group (Category IV)
5. LASA drugs- Same drug, different Dosage forms (Category V)
6. LASA drugs- Same drug, different release characteristics (Category VI)
7. LASA drugs- Same brand name, different composition, different country
(Category VII)
8. LASA drugs- Generic Drug pairs (Category VIII)

85. Examples of medication errors
• An older patient with rheumatoid arthritis died after receiving an
overdose of methotrexate--a 10-milligram daily dose of the drug
rather than the intended 10-milligram weekly dose.
• One patient died because 20 units of insulin was abbreviated as "20
U," but the "U" was mistaken for a "zero." As a result, a dose of 200
units of insulin was accidentally injected.

89. Hospital pharmacist-medication safety
• The hospital pharmacist is best placed to note the quality of the
entire drug distribution chain, from:
• prescribing,
• drug choice,
• dispensing and
• preparation
• administration of drugs,
• and thereby can fulfill a vital role in improving medication safety.