The document discusses medication errors, defining them as failures in the drug treatment process that can lead to patient harm. It emphasizes the prevalence of such errors in healthcare, cites statistics regarding their impact in India, and outlines stages where errors can occur: prescribing, administration, and monitoring. Strategies for preventing these errors, such as proper patient assessment, communication, and the use of checklists and computerized systems, are also highlighted.

1. MEDICATION ERRORS
Dr.Sunanda Nandikol
Pharm-D
Assistant Professor
BLDEA’s SSM College of Pharmacy &
Research Centre,Vijayapura

2. • If we had to live with 99.9 (success rate in industry), we
would have 2 unsafe plane landings per day at O’Hare, 16000
pieces of lost mail every hour and 32,000 bank checks
deducted from wrong bank account every hour ”
— WE Deming

3. MEDICATION ERRORS
• ERROR: Failure to carry out a planned action as intended or
application of an incorrect plan
• A medication error is a failure in the drug treatment process that
leads to or has the potential to lead to harm.
• OUTCOMES OF Medication Errors : A medication error
may result in …
• An adverse event if a patient is harmed
• A near miss if a patient is nearly harmed or
• Neither harm nor potential for harm

4. • EMA: “Medication errors are unintended mistakes in the
prescribing ,dispensing and administration of a medicine that
could cause harm to a patient. They are the most common
preventable cause of undesired adverse events in medication
practice and present a major health burden.”
• FDA: A medication error is “any preventable event that may
cause or lead to inappropriate medical use or patient harm
while the medication is in control of the healthcare
professional, patient, or consumer.”

5. • Adverse drug event (ADE) means an injury or AE resulting
from medical intervention related to use of a drug.
• Adverse Drug Reaction (ADR) is any unwanted effect
caused by drug when used in recommended dosage and is
appropriate.
E.g:-an unexpected allergic reaction in a patient taking a
medication for the first time
• Negligent Adverse event is an injury caused by the failure to
meet standards expected of an average physician or institution.
• Side-effect: a known effect, other than that primarily intended,
relating to the pharmacological properties of a medication.

6. EPIDEMIOLOGY:
• In India the extrapolated figures would be 400,000 deaths due
to ADRs and 720,000 AEs per annum ,
• In a study of over 3500 prescriptions, the use of drugs was
unnecessary in 47 per cent, irrational in 19 per cent and
hazardous in 11 per cent.

7. PREVENTAB
LE
51%
NON
PREVENTAB
LE
49%
ADR RELATED
VISITS

8. INCIDENCE OF MEDICATION ERRORS
61%
25%
14%
Unnecessary drugs Irrational Hazardous

9. 27%
1%16%56%
INCIDENCE OF ADRs
and ADEs
SERIOUS ADRs FATAL ADRs ADVERSE EVENTS FATAL ADEs

10. WRONG
DOSE
22%
INADEQUATE
FOLLOW-UP
25%
INAPPROPRI
ATE DRUG
CHOICE
11%
DECLINE IN
RENAL/HEPA
TIC
FUNCTION
8%
DELAY IN
TREATMENT
8%
KNOWN
ALLERGY
7%
WRONG
DRUG NAME
6%
WRONG
FREQUENCY
6%
DDI
3%
PRACTICING
OUTSIDE
AREA OF
EXPERTISE
3%
WRONG
ROUTE
1%

11. Medication Error may occur during these three stages:-
• Prescribing
• Administration
• Monitoring

12. Prescribing involves
• Choosing an appropriate medication for a given clinical
situation taking individual patient factors into account such as
allergies
• Selecting the administration route, dose, time and regimen
• Communicating details of the plan with:
▫ whoever will administer the medication (written-
transcribing and/or verbal)
▫ the patient
• Documentation.

13. How can prescribing go wrong?
• Inadequate knowledge about drug indications and
contraindications
• Not considering individual patient factors such as allergies,
pregnancy, co-morbidities, other medications
• Wrong patient, wrong dose, wrong time, wrong drug, wrong route
• Inadequate communication (written, verbal)
• Documentation - illegible, incomplete, ambiguous
• Mathematical error when calculating dosage
• Incorrect data entry when using computerized prescribing e.g.
duplication, omission, wrong number
• Look-a-like and sound-a-like medications
• Eg:- Celebrex (an anti-inflammatory) Cerebryx (an
anticonvulsant) Celexa (an antidepressant)

14. How to prevent Prescribing errors
• Use generic names rather than trade names .
• Tailor your prescribing for each individual patient.
• Consider:
▫ allergies
▫ co-morbidities (especially liver and renal impairment)
▫ other medication
▫ pregnancy and breastfeeding
▫ Age,weight of patient
• Learn and practise thorough medication history taking
include name, dose, route, frequency, duration of every drug.

15. • 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.
▫ Practise medication reconciliation at admission to and
discharge from hospital.
• Consider drug interactions, medications that can be ceased and
medications that may be causing side-effects.
• Always include allergy history.
• Know which medications are high risk and take precautions.
• Narrow therapeutic window.
• Multiple interactions with other medications.

16. • Complex dosage and monitoring schedules.
examples:
▫ Oral anticoagulants
▫ Insulin
▫ Chemotherapeutic agents
▫ Neuromuscular blocking agents
▫ Aminoglycoside antibiotics
▫ Intravenous potassium
▫ Emergency medications (potent and used in high pressure
situations)
• Know the medication which are prescribed .

17. • Suggested framework.
▫ Pharmacology
▫ Indications
▫ Contraindications
▫ Side-effects
▫ Special precautions
▫ Dose and administration
▫ Regimen
• Use memory aids.
• Textbooks.
• Personal digital assistant.
• Computer programmes, computerized prescribing.
• Protocols.

18. Administration involves
• Obtaining the medication in a ready-to-use form; may involve
counting, calculating, mixing, labeling or preparing in some way.
• Checking for allergies.
• Giving the right medication to the right patient, in the right dose, via
the right route at the right time.
• Documentation.

19. How can drug administration go wrong?
• Wrong patient.
• Wrong route.
• Wrong time.
• Wrong dose.
• Wrong drug.
• Omission, failure to administer.
• Inadequate documentation.

20. Preventing Errors during Administration
• When administering medication:
▫ check for allergies
▫ check the 5 Rs
• Remember computerized systems still require checking.
• Always check and it will become a habit!
• Some useful maxims …
• Unlabelled medications belong in the bin.
• Never administer a medication unless you are 100% sure you know
what it is.
• Practice makes permanent, perfect practice makes perfect.
▫ so start your checking habits now.
• Encourage patients to be actively involved in the process.

21. • When prescribing a new medication provide patients with the
following information:
▫ Name, purpose and action of the medication
▫ Dose, route and administration schedule
▫ Special instructions, directions and precautions
▫ Common side-effects and interactions
▫ How the medication will be monitored
• Encourage patients to keep a written record of their medications and
allergies.
• Encourage patients to present this information whenever they
consult a doctor.
• Report and learn from medication errors.
• Safe practice skills for medical students to develop and practise …
• Whenever learning and practising skills that involve medication use,
consider the potential hazards to the patient and what you can do to
enhance patient safety.

22. Monitoring involves …
• Observing the patient to determine if the medication is working,
being used appropriately and not harming the patient.
• Documentation.
How can monitoring go wrong?
• Lack of monitoring for side-effects.
• Drug not ceased if not working or course complete.
• Drug ceased before course completed.
• Drug levels not measured, or not followed up on.
• Communication failures.
• Patients on multiple medications.
• Patients with another condition, e.g. renal impairment, pregnancy.
• Patients who cannot communicate well.
• Patients who have more than one doctor.
• Patients who do not take an active role in their own medication use.

23. Preventing errors during monitoring
• Being aware of common pitfalls in medications you prescribe
• Memory aids and alerting systems to help doctors notice
potential adverse drug interactions
• Monitoring medication side effects when indicated
• Encourage the patient to ask more questions

24. Types of Medication Errors
The common errors are:
• Knowledge-based errors
• Rule-based errors
a) The misapplication of a good rule or the failure to apply a good
rule;
b) The application of a bad rule.
• An action-based error.
▫ Technical errors
• Memory-based errors
• Cognitive errors - such as incorrect diagnosis

25. Prevention of errors
1. Reduced reliance on memory by using checklists, protocols, and
computerised decision aids for prescription writing.
2. Improved information access with availability of computerised
medical record at bedside.
3. Error proofing - use of forcing functions in computer programmes
so that a physician can not enter an overdose or prescribe a
medication to which the patient is allergic.
4. Standardisation of drug doses and times of administration, of
information displays, equipment and supplies location in hospitals.
5. Training of doctors, nursing and other staff in safe practice.

26. MEDICATION SAFETY
•Knowledge requirements.
•Understand the scale of medication error.
•Understand the steps involved in a patient using medication.
•Identify factors that contribute to medication error.
•Learn how to make medication use safer.
•Understand a doctor’s responsibilities when using medication.
•Performance requirements.