medication errors in brief

1. Medicatio
n Errors
Guided by
Dr. V. M. Motghare
Prof & Head
Dept. of Pharmacology
Dr. Swarnank Parmar
JR-2
Dept. of Pharmacology
GMC, Nagpur 1

2. Overview
• Definition
• Epidemiology
• Classification
• Causes of errors
• Factors contributing & risks
• Steps to prevent medication errors
• Summary
2

3. Definition
• “Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in control of the health care professional,
patient, or consumer”
• May occur at any time, from the prescription to
consumption of the medicines by the patient
• Problems & sources of medication errors are
multidisciplinary & multifactorial
3

4. • Errors occur from-
– Lack of knowledge
– Unclear or erroneous labeling of drug
– Misidentification of patient
– Mental lapses or
– Verification errors
• Errors committed by both experienced &
inexperienced staff
4

5. Epidemiology
• Interesting but horrifying fact-
- More people in USA die in a given year as a result of
medical errors than from motor vehicle accidents, breast
cancers, or AIDS
• Majority are medication errors
• Indian study of paediatric intensive care unit reported
68.5% of all errors were medication errors
5

6. • Reported epidemiology of this iatrogenic disease
related to medication error- tip of the iceberg
• Numbers reported can be misleading due to-
 Small % of errors & adverse drug events detected, even
smaller number are reported
 Inconsistencies in way the errors reported & counted
 Most studies have looked errors only in inpatient settings
 Most studies focus on errors of commission(fails to
consider errors of omission)
6

7. Classification
Errors
When actions are intended but not performed
Mistakes
Errors in planning action
Skill based errors (slips & lapses)
Errors in executing correctly planned actions
Knowledge-
Based errors
2. Rule- based
errors
2a. Good
rules not
applied or
misapplied
2b. Bad
rules
3. Action-based
errors (slips)
4. Memory-based
errors(lapses)
3a.
Technical
errors
7

8. Intention
Mistakes
Plan cannot
reach target
Intended
outcome
Slip/Lapse
Error in
implementing
plan
Check
8

9. Sources of errors
9

10. • Errors of Omission: errors related to prescription, drug
dispensing by pharmacist, drug administration by medical
personnel like nurses & patient themselves
• Errors of Commission: most common form of errors
encountered in clinical practice, this include –
1.) Wrong phenomenon
2.) Drug interaction related
3.) Communication failure
4.) Failure to follow appropriate policies related to drug use
5.) Failure to follow drug-specific instructions
6.) Overuse of a drug(irrational drug use &
polypharmacy)
Causes of errors
10

11. 1. “Wrong” phenomenon –
- Wrong drug, wrong dose, wrong substitution for a drug,
wrong patient, wrong regimen, wrong route
2. Drug interaction related errors –
- Food-drug interaction, drug- drug interaction or
interactions with other alternative forms of medicine
- Responsible for medication errors, which may lead to
serious adverse events, sometimes hospitalization or
death of patient
11

12. 3. Communication failure –
- Failures during the process of patient management
- Includes illegible handwriting, incomplete prescribing
order, vague instructions, prescription not recognized &
unknown prescriber
- Common errors include: ‘g’ mistaken for ‘mg’, ‘4’ mistaken
for ‘U’, decimal point(‘.1’ read as ‘1’)
12

13. • Some other recognized types of medication errors-
 Incomplete patient information
 Drug information unavailable
 Miscommunication of drug orders
 Confusion in drug names
 Misuse of zeros & decimal points
 Confusion in dosing units
 Inappropriate abbreviations
13

14. Swiss Cheese Model
• Pictorial model for medication errors
• Defences against error displayed as thin layers with
holes that describes latent errors in system
• Each layer successively represents the prescriber,
pharmacist, nurse & patient related defences
• Missed error successively at various defence levels,
reaches the patient
14

15. 15

16. Types of errors
• Prescribing errors
• Dispensing errors
• Administration errors
16

17. Prescribing errors
Incorrect drug
selection for a
patient
Errors in
quantity &
indication
Prescribing
contraindicated
drug
17

18. Factors contributing
 Lack of knowledge of the prescribed drug, dose, patient
details
 Illegible handwriting
 Inaccurate medication history taking
 Confusion with the drug name
 Inappropriate use of decimal points
 Use of abbreviations (e.g. AZT)
 Use of verbal orders
18

19. 19

20. Risk factors for prescribing
errors
Work environment & workload
Miscommunication within team
Physical & mental well being
Lack of knowledge
Inadequate training
Low perceived importance of prescribing
Absence of self awareness of errors
20

21. Reducing prescribing errors
• Electronic prescribing reduces errors due to
illegible handwriting
21

22. • Computerized physician order entry system eliminates
need for transcription orders by nursing staff
22

23. Dispensing errors
• Receipt of the prescription supply of a
dispensed medicine to patient
• Occurs primarily with drugs having similar name or
appearance
• Example :lasix® (frusemide) and losec® (omeprazole)
• Other potential dispensing errors include
– wrong dose
– wrong drug or
– wrong patient
23

24. Reducing dispensing errors
• Ensuring a safe dispensing procedure
• Separating drugs with similar name or appearance
• Unit dose medication dispensing
• Automated medication dispensing system
• Bar code medications for dispensing & administration
(patient given barcoded wristband)
24

25. Administration errors
• Discrepancy between drug received by patient & drug
therapy intended by prescriber
• Errors of omission - the drug is not administered
• Incorrect administration technique & administration of
incorrect or expired preparations
• Deliberate violation of guidelines
25

26. Contributing factors
• Failure to check patient’s identity prior to
administration
• Environmental factors such a noise,
interruptions, poor lighting
• Wrong calculation to determine the
correct dose
26

27. Reducing administration errors
• Checking patient’s identity.
• Ensuring dosage calculations are cross
checked independently by another health care
professional before drug is administered
• Ensuring medication given at correct time
• Minimizing interruptions during drug rounds
27

28. Drugs commonly associated with
medication errors
• Analgesics-
– Unnecessary use of opioid analgesics (over sedation of
patient)
– Errors reported are due to wrong route of
administration
– Failure to monitor clinical parameters (heart rate,
respiration & blood pressure), resulted in major adverse
outcomes related to opioid use
28

29. • Antibiotics-
 Irrational use
• Anticoagulants-
 Inadequate therapeutic dosing
 Failure to monitor blood levels
• Cardiovascular agents-
Errors due to overdose
Failure to identify drug-drug interactions due to
polypharmacy 29

30. • Diabetic medications-
– Overdose of hypoglycemic drugs (insulin)
– Overenthusiastic patients trying to keep blood glucose
within normal limits
– Failure to take drugs in relation to meals
– This group of drugs signifies importance of patient
education by treating physicians
30

31. LOOK ALIKE SOUND ALIKE
• Existence of confusing drug names is one of the most
common causes of medication error
• With thousands of drugs currently in market, potential for
error due to confusing drug names is significant
• Contributing factors are
– illegible handwriting,
– incomplete knowledge of drug names
– newly available products,
– similar packaging or labelling
– similar clinical use
– Similar strengths, dosage forms, frequency of administration 31

32. Major effect on therapeutic
success
Brand name(Generic name) Brand name(Generic name)
Benzol (Danazol) Benzole (Albendazole)
Alparazole (Alprazolam) Adprazole (Omeprazole)
Amsat (Ampicillin) Amset (Amlodipine)
Adcom (Telmisartan) Adcon (Fluconazole)
Alflox (Norfloxacin) Alfox (Oxcarbazepine)
Dazolic (Ornidazole) Dazolin (Sertraline)
32

33. Minor effect on therapeutic
success
Brand name(Generic name) Brand name(Generic name)
Aquamide (Furosemide) Aquazide (Hydrochlorthiazide)
Disprin (Aspirin 350mg) Dospin (Aspirin 75mg)
Epitab (Phenytoin) Epitan (Phenobarbitone)
Ostofit (Glucosamine) Ostrobit (Ca. carbonate)
Wormnil (Mebendazole) Wormonil (Albendazole)
33

34. No significant effect on
therapeutic success
Brand name(Generic name) Brand name(Generic name)
Avcif (Cefixime) Avcip (Ciprofloxacin)
Atmox (Amoxicillin) Atrox (Roxithromycin)
Cefit (Cefixime) Cefiz (Cefpodoxime)
Ceftab (Cefuroxime) Ceftas (Cefixime)
Deplin (Sertraline) Depnil (Clomipramine)
34

35. 35

36. Strategies to prevent errors by
LASA drugs
• Use of novel dosage delivery devices to distinguish products
with similar names
• Print generic and brand names on unit-dose packaging, when
possible
• Use of TALL MAN lettering to emphasize the spelling of drug
names in medication storage areas (e.g. lamIVUDine &
lamOTRIGine )
• Include dosing limits for medications with similar indications
36

37. Steps to prevent medication
errors
Targeted physician education on optimal medication
use
Inclusion of clinical pharmacists in decision making
activities
Computerized order entry by prescriber & medication
checking
Standardize processes & equipment
Avoid use of unknown abbreviations & symbols
Double check patients having allergies before
prescribing 37

38. Check the expiry date of the drug before
administration
Medication Reconciliation
Standardised ordering and administration
Training, education, and organisational interventions
Preparing medicine in well lighted room
38

39. Six step approach by WHO for
good prescribing
• Evaluate & clearly define patient’s problem
• Specify therapeutic objectives
• Select appropriate drug therapy: P-drug & STEPS approach
(Safety, Tolerability, Effectiveness, Price, Simplicity)
• Initiate therapy with appropriate details
• Give information, instructions & warnings
• Evaluate therapy regularly (e.g. Monitor treatment results)39

40. Role of regulatory authorities
• Important role in preventing medication errors
• Review of drug labels & nomenclature greatly enhances
preventive strategies
• FDA provides guidance to industry to maintain proper drug labels
• Public education by regulatory agencies improves medication use
• Emphasis laid on having package insert in vernacular languages
40

41. Role of organizations
• Computer software installation by FDA to analyze similar
drug names
• Potentially confusing names rejected
• FDA reviews 300 brand names in a year before they are
marketed to avoid confusion of LASA drugs
• FDA encourages pharmacists & other health professional to
report any medication errors
41

42. Role of prescribers
• Doctors should have knowledge of generic names & brand
names of available drugs in their local setting
• Specify dosage form, drug strength & complete directions
on prescriptions
• Using both brand name & generic name on prescription
• Purpose of medication
• Legible handrwiting
42

43. Role of Pharmacist
• Refer back to doctor if any confusion
• Basic knowledge of dosing regimens for commonly used
drugs
• Computer reminder for serious confusing name pairs to
avoid errors in prescription
• Stickers of ‘Alert’ in areas where LASA drugs stored
• In case of wrong prescription, pharmacist should not react
in front of patient 43

44. Role of nursing staff
• Education & proper training important in reducing
medication related errors
• Most errors do not reach patient because of barrier role
played by a nurse
• Independent calculations of paediatric doses by more than
one person
• Should be aware of correct storage requirements for drugs
• Development of standardized dose & rate charts for
products such as vasoactive drugs 44

45. Patient & Physician education
• Regular short courses/training to junior residents by academic
institution for good prescription writing practices
• Prescriber should also consider –
– Age of patient
– Any physical disability
– Weak eye sight, before prescribing
• Patient educated regarding correct use of prescription & over
the counter medicines
45

46. • Patient should confirm name & strength of prescribed drugs
before leaving doctor’s office
• Educated about the storage conditions of drugs (e.g. Insulin)
• Keeping medicines away from reach of children also should
be emphasized
• Patient should carry all previous prescriptions to avoid
repeating the drug or notice any change in prescriptions
46

47. Summary
•Stay alert !
•Question !
•Learn !
47

48. Referneces
• Medication Errors: Causes & its prevention, Singh I, Shafiq
N, Malhotra S;Drugs Bulletin Vol.XXXVI No. 2, April 2011
• British journal of clinical pharmacology;67:6, 2009
• Look alike & Sound alike drug brand names; Mukundraj S
Keny, PV Rataboli; Indian journal of clinical practice, Vol. 23,
no.9, February 2013
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