Error detection through an active management and effective reporting system discloses medication errors and encourages safe practices.

1. Medication Error
&
Drug Calculation
Group Members
Kawish Perviez
Shaista Bibi
Shakeela Bibi
Nageena Nargis
Sonia Paul

2. Objectives
At the end of the presentation the learner will be able to ;
• Pre test of work shop
• Define medication error
• Explain the sources of medication error
• Describe epidemiology of medication error in Pakistan
• Differentiate between different types of medication error
• Identify environmental causes of medication error
• Drug Calculation

4. Errors
• An error is a deviation from accuracy or correctness
• A mistake is an error caused by a fault: the fault being
misjudgment, carelessness, or forgetfulness

5. Medication Error
• "A 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 health care professional,
patient, or consumer.”
NCC for Medication Error Reporting & Prevention 2015

6. Cont.
Medication error events may be related to
 Professional practice
 Health care products
 Procedure and system
These including prescribing, order communication, product
labeling and packaging
NCC for MERP 2018

7. Sources of medication Error
• Inaccurate recording and transcribing orders
• Unclear or erroneous labeling of drugs
• Misidentification of client
• Incomplete delivery of drugs
• Miscommunication of drug
• Verification error
• Inadequate or inaccurate knowledge base
• Time and performance pressure, staffing and work flow

8. Epidemiology
• 80,000 people annually died in the United States alone due to
medication errors.
• Estimated that annually 400,000 to 500,000 people die in
Pakistan as well owing to wrong administration of drugs, and
other lethal errors in medication.
• The main error rate was 5.5% and pharmacists contributed an
higher error rate of 2.6% followed by nurses (1.1%) and
physicians (1%).

9. Reporting medication error at AKUH
• The nursing division at AKUH captures 6 to 7 medication
errors per month, and compiles an average of 72 to 78 errors
annually.
• The pharmacy department reports 4056 annual potential
medication errors which are identified and prevented before
actual error occurs. Combining these two reports contributes a
0.7% medication error rate in 2003.
• In 2004, medication incidences were 128 and pharmacy
reported 5933 potential medication errors giving an error rate
of 0.98% (unpublished data).
• The current estimates of medication error rate at AKUH are
considered low, as many errors are undocumented and
unreported.

10. Classification of medication error
• The medication error may be classified into mistakes, slips or
lapses
• Medication error may also be classified according to where
they occur in the medication use cycle i.e., at the stage of :
Prescribing
Dispensing
Administrating
Monitoring and compliance error

11. Prescribing Error
• Involves wrong dose, illegible sigs, wrong frequencies
• Incorrectly transcribing verbal orders from physicians
• Illegible hand writing
• Confusion with drug name

15. Dispensing Error
From the receipt of the prescription in the pharmacy to the supply
of dispensed medicine to the patient
• Confusing the name of one drug with another
• Two or more drugs have similar appearance or similar name
(LASA)
• For example: inj.calcium gluconate and inj.aminophyline ,
amiloride 5mg and amlodipine 5mg tablets

16. Administrating Error
Discrepancy between the drug therapy received by the patient and
the drug therapy intended by the prescriber
• Wrong administration technique
• Administration of expired drugs
• Administration of wrong preparation
• Extra or wrong dose error
• Wrong route error
• Wrong rate error
• Wrong time error

17. Monitoring and compliance Error
Monitoring Error:
• Failure to review a prescribed regimen for appropriateness
• Failure to use appropriate clinical or laboratory data to assess
the patient’s response to prescribed therapy
Compliance Error:
• Inappropriate patient behavior regarding adherence to
prescribed medication regimen
• For example:
– Patient does not complete antibiotics therapy- saves few
doses

18. Environment causes of Errors
• Too many phone calls
• Work overload/ full patient census
• Lack of concentration
• No one available for double check
• Staff shortage
• Similar drug names

19. vI

22. References
• MERP N. National Coordinating Council for Medication Error
Reporting and Prevention. About Medication Errors: What is a
Medication Error. 2015.
• Cohen MR, editor. Medication errors. American Pharmacist
Association; 2007.
• Aronson JK. Medication errors: definitions and classification.
British journal of clinical pharmacology. 2009 Jun
1;67(6):599-604.
• Medication errors cause half a million deaths in Pakistan, say
pharmacists, Published in Dawn, October 11th, 2017
• Khowaja K, Nizar R, Merchant RJ, Dias J, Bustamante-
Gavino I, Malik A. A systematic approach of tracking and
reporting medication errors at a tertiary care university
hospital, Karachi, Pakistan. Therapeutics and clinical risk
management. 2008 Aug;4(4):673.