Easiest way to learn about Medication error, Types of medication Error and reporting of Medication error

1. MEDICATION ERRORS
(Department of Clinical Pharmacology, Jaypee Hospital-Noida)
Dr.Irfanul Haque
Clinical Pharmacologist

2. • The national co‐ordinating council for medication
error reporting and prevention[NCCMERP] defines a
medication error as follows;
"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.
• Errors mayoccur at anytime, from the prescription to
consumption of the medicines by the patient.

3. MEDICATION ERRORS
Errorscommitted by both experienced & inexperienced
staff
• Errors mainly occursdue to-
– Lackof knowledge
– Unclear labeling of drug
– Misidentification ofpatient
– Mental lapsesor
– Verificationerrors

4. Epidemiology
• Interesting but horrifyingfact-
•-More people in USAdie in agiven year asa
result of medicalerrors than from motor
vehicle accidents,breast cancers,or AIDS
• Numbers reported canbe lessdueto-
Small%of errors & adverse drug events
detected, even smaller number arereported
Most studies have looked errors only in inpatient
settings

5. Causes of Errors
• Overload/Weekends
• Too many patients
• Lack of Concentration
• Double check not possible
• Shortage of staff
• Illegible Prescription
• Human Errors
• Abbreviations
• Verbal Orders
• Look alike Sound alike drugs
• Wrong dosage calculations

6. According to ASHP(american society of hospital pharmacist) gui
delines, medication error can be catagorized into 11 types
• 1.prescribing error
• 2.omission error
• 3.improper dose errOr
• 4.unauthorized drug error
• 5.deteriorated drug error
• 6.wrong time error
• 7.wrong dosage form error
• 8.wrong drug preparation error
• 9.wrong administration technique error
• 10.monitoring error
• 11.compliance error

7. • Prescription Errors
• Transcription Errors
• Indenting Errors
• Dispensing Errors
• Administration Errors
• Documentation Errors
• Monitoring Errors

8. Prescription Errors
A prescription error occurs at the time where Doctor
prescribe drugs for a specific patient.
Prescription error may include the following
1. Lackof knowledge of the prescribeddrug, dose,patient details
2. Illegiblehandwriting
3. Inaccurate medication historytaking
4. Inappropriate useofdecimal points
5. Useof abbreviations(e.g MgSo4, AZT)
6. Useof verbal orders
7. Therapeutic Duplication
8. Drug Drug Interaction or Drug food interaction
9. Drugs order in small letters

9. Illegible Handwriting
Write complete and clear order with Drug name
Dosage form, Strength, Dose, Route, frequency

10. Reducing Prescription Errors
Computerized physician order entry(CPOE) system bythe
help of Clinicalpharmacist reduces the errors.

11. Transcription Errors
• Transcription is a process of making an identical copy of
prescription in the medical records. Error that occurs during
this process is known as Transcription Error.
Transcription Errors are follows-
1. Several sheets of paper and stages from physician’s order
2. Incomplete or illegible prescriber orders
3. Wrong Drug dose
4. Wrong Route or frequency
5. Wrong Patient
6. Delay in Transcription.
Note –Transcription staff has to high light High risk medicine in
drug chart

12. Indenting Errors
• Error that occurs during the process of
ordering drugs through Computer system
Indenting errors includes-
1. Wrong Drug
2. Wrong dose
3. Wrong quantity
4. Delay in Indenting

13. A dispensing error is a discrepancy between a prescription and
the medicine that the pharmacy delivers to the patient
Most Prevalent Dispensing Errors are-
1.With Look alike and sound alike drugs
2.Failure to identify drug interactions or contraindications
3.Dosage miscalculations

14. Dispensing errors
Others Dispensing errors
Wrong Drug
Wrong Dose
Wrong Patient
Delay in Dispensing

15. Reducing Dispensing Errors
• Ensuringasafe dispensingprocedure
• Separatingdrugswith similarnameor appearance(LASA Drugs)
• Useof TALLMANlettering to emphasizethe spellingof drug
namesin medication storage areas(e.g. lamIVUDine &
lamOTRIGine)
• Unit dose medicationdispensing
• Awareness of high risk Medication like potassium chloride
and cytotoxic agents

16. Administration Errors
Discrepancybetween drug receivedby patient & drug
therapy intended byprescriber
• Errorsof omission -the drug isnot administered
• Incorrectadministration technique & administration
of expired preparations
• Deliberate violation ofguidelines

17. Incorrect Administration technique
• SC injection administered too
deep
• IV drug is allowed to infuse via
gravity instead of using IV pump
• Instilling eye drops in wrong eye

18. Contributing Factors
• Failureto checkpatient’s identity prior to
administration
• Environmental factors such anoise, interruptions, poor
lighting
• Wrong calculation to determine the correct dose

19. Reducing Administration Errors
• Checkingpatient’s identity.
• Ensuring dosage calculations arecross
checkedindependently by another health care
professional before drugisadministered
• Ensuringmedication given at correct time
• Minimizing interruptions during drug Administration

20. Documentation Errors
• Allergy Documentation
• High light of High risk medication
• Administration without counter sign in high
risk medication
• Verbal order not Documented

21. Monitoring Errors
• After administration of Drugs to patient,
Patient has to monitor for therapeutic
response of Drugs.
• Monitor the patient after Discharge from
Hospital.

22. Medication Errors Categorization
Category Event
A Circumstances or event that has a capacity to cause error.
B Error occurred but didn’t reach the patient.
C An error occurred that reached the patient but did not
cause any harm.
D An error occurred that reached the patient and required
monitoring to confirm that it resulted in no harm to the
patient and /or required intervention to preclude harm.
E An error occurred that may have contribute to or resulted
in temporary harm to the patient and required
intervention.

23. Category Event
F An error occurred that may have contribute to or
resulted in temporary harm to the patient and
required transfer to other unit/critical care.
G An error occurred that may have contribute to or
resulted in permanent harm of the patient.
H An error occurred that required intervention to
sustain life.
I An error occurred that may have contribute to or
resulted in patient.

24. Policy on reporting of Errors.
• When an error is identified, it shall be reported on a “INCIDENT ERROR
REPORT FORM” by nurse in charge and the doctor on duty immediately.
• Reporting of an error must be part of the ordinary routine. its non-
punitive so that staff does not have to be afraid of repercussions.
• Continuous monitoring and frequent assessments shall be done for the all
patients.
• A Medication Error form shall be signed with name by the reporting
person.
• The medication error form shall be submitted to the Clinical
Pharmacologist.

25. Exercise-1
Following statement is true or false..
1.Inj.Colistim 300mg SC Once daily
2.Tab.Atorvastatin 20mg PO/OD at 10 am.
3.Tab.Metrogyl 500mg PO/TDS.
4.Inj.Clexane 0.4mg SC/OD.
5.Inj.Rantac 150mg IV/BD.
6.Inj.Zosyn 4.5 mg IV/TDS.
7.Inj.Clexane 0.4ml IV/BD.
8.Inj.Zyrop 4000 IU IV/OD.
9.Inj.Ciplox 500mg IV/BD.
10.Inj.Oflox 200mg IV/BD.

26. Exercise-2
• Tab.Levoflox 750mg PO/BD
• Tab.Dolo 650mg PO/TDS and Inj.Perfalgan 1 gm
IV/QID
• Tab.Pan D and Tab. Domperidone
• Tab.Metpure and Tab Embeta XR.

27. Exercise-3
• Inj.Caspofungin 50mg in 100ml 5% Dextrose.
• Inj.Cordarone 200mg in 100ml NS.
• Inj.Fungisome 50mg in 100ml 5% Dextrose.