Medication errors- Factors, Preventive Measures & Responsibilities of Healthcare professionals regarding the Medication errors.

1. - D.BHUVANA
PHARM.D IV YEAR
MEDICATION ERRORS
Clinical Pharmacy

2. Medication Error:
 A medication error is an episode
associated with the use of a
medicine that should be
preventable through effective
control systems.

3.  Factors that may influence the
Medication Errors:
 Factors associated with health care professionals-
 Lack of therapeutic training
 Inadequate drug knowledge and experience
 Inadequate knowledge of the patient
 Inadequate perception of risk
 Overworked or fatigued health care professionals
 Physical and emotional health issues
 Poor communication between health care professional and with patients

4.  Factors that may influence the
Medication Errors:
 Factors associated with patients-
 Patient characteristics (e.g., personality, literacy and language barriers)
 Complexity of clinical case, including multiple health conditions, polypharmacy and high-risk
medications
 Factors associated with the work environment-
 Workload and time pressures
 Distractions and interruptions (by both primary care staff and patients)
 Lack of standardized protocols and procedures
 Issues with the physical work environment (e.g., lighting, temperature and ventilation)

5.  Factors that may influence the Medication
Errors:
 Factors associated with medicines-
 Naming of medicines
 Labelling and packaging
 Factors associated with tasks-
 Repetitive systems for ordering, processing and authorization
 Patient monitoring (dependent on practice, patient, other health care settings, prescriber)
 Factors associated with computerized information systems-
 Difficult processes for generating first prescriptions (e.g. drug pick lists, default dose regimens and missed
alerts)
 Difficult processes for generating correct repeat prescriptions
 Lack of accuracy of patient records

6. Categories of medication errors:
The American Society of Health System Pharmacists (ASHP) definition of
medication errors includes prescribing, dispensing, medication administration
and patient compliance errors.
They define the following categories of medication errors:
• Prescribing errors
• Omission errors
• Wrong time errors
• Unauthorised drug errors
• Improper dose errors

7. • Wrong dosage form errors
• Wrong drug preparation errors
• Wrong administration or technique errors
• Deteriorated drug errors
• Monitoring errors
• Compliance errors
• Other medication errors

8. Prescribing errors:
 Occurs when prescriber orders drug for specific patient
 drug
 dose
 dosage form
 route of administration
 length of therapy
 number of doses
 administration
 drug concentration
 inadequate or incorrect instructions for use
 illegible handwriting

9. Omission errors
 Failure to administer an ordered dose
 Omitted dose is not an error when
 cannot take anything by mouth
 providers are waiting for drug level results
 patient refuses

10. Wrong time error:
Standardised administration times
Acceptable interval surrounding
scheduled time

11. Unauthorised drug errors:
 Administration of medication to patient without
proper authorization by prescriber
 Medication for patient given to another patient
 Nurse gives medication without prescriber order
 Patients “share” prescription

12. Improper dose errors:
 Occurs when dose is administered less or greater
than prescribed dose.
 Can also occurred when additional dose is
administered
 Inaccurate measurement of the dose

13. Wrong dosage form errors
Doses administered as different form
than ordered.
Example: Ophthalmic ointment
administered
When a solution was implicated.

14. Wrong drug preparation errors:
 Reconstituting oral suspension with incorrect volume
For instance, using bacteriostatic saline instead of
sterile water to reconstitute lyophilized powder for
injection

15. Wrong administration or technique
errors
Administrating the drug in a improper way or other way than as
directed.
Examples:
 subcutaneous injection that is given too deep
 intravenous (IV) drug is allowed to infuse via gravity instead
of using an IV pump
 instilling eye drops in wrong eye

16. Deteriorated drug errors:
 Monitoring expiration dates is very important
 Drugs used past their expiration date may have lost potency
 may be less effective or ineffective
 Refrigerated drugs stored at room temperature may decompose & lose efficacy
Tetracycline as exposed to
higher temperatures turns
out its colour to brown and
become viscous.

17. Monitoring errors:
 Inadequate drug therapy review
Examples:
 Ordering serum drug levels but not reviewing them
 Not ordering drug levels when required
 Prescribing an antihypertensive drug & then failing to check
the blood pressure.

18. Compliance errors:
 Failure to adhere to the prescribed drug
 Example: patient does not complete antibiotics
therapy-saves a few doses

19. Other medication errors:
 Medication dispensed without adequate patient education

20. Prevention:
7 Rights of Medication administration:
 The 7 R’s
1. Right patient
2. Right drug
3. Right dose
4. Right time
5. Right route
6. Right dosage form
7. Right documentation

21. Preventing Medication errors:
 Establish consensus group of physicians, nurses, and pharmacists to select best practices.
 Develop written procedures with guidelines and checklists for IV fluids and high-risk medicines (e.g., insulin,
heparin, narcotics).
 Require legible handwriting and complete spelling of medicine name.
 Use standardized notation.
 Doses given in mg, mcg, g. Leading zero used for values < 1 and no trailing zero (e.g., 0.2 mg instead .2 mg; 2
mg instead of 2.0 mg)].
 Write route of administration on all orders.
 Write out directions completely (e.g., “daily” not “QD” or “OD”).
 Limit use of telephone and oral orders to emergency situations.
 Confirm identity of patients before administering medication.
 Use standard administration times for hospitalized patients.

22.  For lookalike and sound alike names, establish a policy requiring that prescribers write both brand
and generic names.
 Use pharmacy staff to help prevent errors.
SOUND ALIKE DRUGS
GROUP-A GROUP-B
EPIDOSIN EPISOLIN
SELEGINE SALAGEN
CLOBAZAM CLONAZEPAM
SULFASALAZINE SULFADIAZINE

23. LOOK ALIKE DRUGS