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Medication safety lecture 2
This document provides information about medication safety and errors. It discusses the extent of medication errors, where they occur in the medication use process, common error types, contributing factors and examples. The six main stages of the medication use process are procurement, prescribing, transcribing, dispensing, administering and monitoring. Transcription errors account for around 50% of medication errors. Administration errors are the cause of about 40% of medication errors. The severity of errors is also categorized. The goal is to prevent errors from occurring and recurring through understanding the medication use system and error analysis.
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Medication safety lecture 2
- 1. Medication Safety Course Ph:Badr A Taher Master Degree DIC Supervisor. MMCH. KSA Head Of Medication Safety Committee Member Of: P&T Committee. Pharmacy And Nurse Committee
- 2. INSPIRED BY TRUEEVENTS 2
- 3. Medication Safety WorkFlow Prevent From occurring Prevent From Reoccurring 3
- 4. The Extent ofthe Medications Error problem In the Institution of Medicine report: 44,000 to 98,000 Americans die each year from medical error, with an associated cost of$17 to $29 billion. 4
- 5. Error Occurrence حدوثالخطأ 5 Errors arenot surprising given the fact that human beings by their very nature make errors.
- 6. Error Analysis Theory الدوائيالخطأ تحليل 6 Reasons of System Failure: Swiss Cheese Model by James Reason
- 7. Note: In Figures9–12, the abbreviations stand for the following: “Proc” for the procurement node; “Presc” for the prescribing node; “Trans/Doc” for the transcribing/documenting node; “Disp” for the dispensing node; “Admin” for the administering node; and “Monit” for the monitoring node. Types of Medication Errors (cont.) الدوائية األخطاء أنواع(تابع) Comparison of Medication Error Reports by Process Node 7 The six nodes are (1) procurement (2) prescribing; (3) transcribing/documenting; (4) dispensing, (5) administering,; and (6) Monitoring medication. http://www.unmc.edu/rural/documents/pr06-08.pdf
- 8. Doctors and 10% 8 Cptopriland Mercaptopurine Meropenem and Imipenem Amikacin and Aminocaproic acid
- 9. Transcription Error IS 50%of medication errors 9 Ceftriaxone Cefazoline Cefepime Cefalexin cefuroxime Cefotaxime Ceftazidime…
- 10. 3. Dispensing Error الدواءصرف في خطأ • Dispensing errors occur at a rate of 5-8 % wrong strength or product. 10
- 11. 3. Dispensing Error(cont.) صرف في خطأالدواء(تابع) Example of Dispensing of LASA Factor: 7,8 (R and P) ,9,10,13. Exjade (Deferasirox) once daily # Ferriprox (Deferiprone)Three Times per day. Methotrexate frequency is per week not daily. Pen G Sodium (IV) # Pen G benzathine(IM) Ampho B # Ampho B liposomal (not equal) Alprostadil Inj # Prostaglandin E2 Tablet. 11
- 12. 4. Administration Error خطأإعطاءفيالدواء 40 % of medication errors. 12
- 13. Administer the medication Evaluatethe patient Review warning, interaction & allergy Confirm the transcription Review the prescription orderSteps of medication administration: 13 4. Administration Error خطأإعطاء فيالدواء
- 14. Contributing factors todrug administration errors include : • A failure to check the patient’s identity • Storage of similar preparations in similar areas. 14 4. Administration Error خطأإعطاء فيالدواء
- 15. 4. Administration Error(cont.) الدواء إعطاء في خطأ(تابع) The intravenous route of administration is a particularly complex process during which errors frequently occur 15 Click here
- 16. EXAMPLE • Extravasation • Vancomycin •Ranitidine • Immunoglobulin • Ampicillin 16
- 17. EXAMPLE • Concentrated electrolyteand precipitation (check diluent color/ turbidity) • Emergency Floor stock : labetalol 17
- 18. EXAMPLE • Insulin rate •Insulin and NGT • Dextrose 50%:Thrombosis • Heparin in OR bleeding: protamine / Automatic Stop Order • Ketamine / respiratory / naloxone 18
- 19. EXAMPLE • Chemo(METHO) andpregnant • Usual vancomycin frequency q 6 but 24 hour? • 1 mg = 1000 mcg( Digoxin) 19
- 20. EXAMPLE • Iron toxicitycould lead to liver damage • Anaphylactic shock 20
- 21. EXAMPLE • Iron Testdose: 25 mg over 15 minutes. • Epipen (Adrenaline) 21
- 22. PROPHYLACTIC AB • Cefazolinover 5 minutes • Clindamycin / gentamicin / metronidazole: 30 minutes • Ciprofloxacin: 1 hour • Within one hour to start operation Or wound infection will occur 22
- 23. 4. Administration Error(cont.) الدواء إعطاء في خطأ(تابع) Unauthorized Drug error: 23 Example of administration of a discontinued drug : The physician prescribe captopril: hold Captopril if BP <90 mmHg but the Nurse administered the Captopril while the patient BP is 80 mmHg. The patient transfer to the Critical Care Unit.
- 24. 24 A 3-day-old infantweighing 1.3 kg was prescribed total parenteral nutrition containing 1 unit of regular insulin per each 327-mL bag. A pharmacy technician mistakenly added 1 mL of regular insulin (100 units) rather than 1 mL of a pharmacy- prepared dilution of 1 unit/mL regular insulin. The mistake was caught 2 hours later when the infant's blood glucose measured 3 mg/dL. Rapid treatment with dextrose boluses ensued, and the blood glucose returned to normal within 12 hours. 4. Administration Error (cont.) الدواء إعطاء في خطأ(تابع)
- 25. 4. Administration Error(cont.) الدواء إعطاء في خطأ(تابع) Types of Administration errors (cont.): Wrong Dosage Form Error :(plain aspirin instead of enteric-coated) Wrong Time Error: (in 30-minute window medications) 25 5
- 26. A covering physicianadmitted a patient with Hodgkin’s lymphoma to a medical unit. At home, the patient had been taking hydromorphone 2 to 4 mg orally for pain. The covering physician prescribed the same medication, but also wrote an order for hydromorphone 2 to 4 mg IV every 3 hours for pain if the patient was unable to tolerate oral fluids. 26 Categorization of Medication Error according to the severity (cont.)
- 27. Like the physician,the nurses on the unit did not recognize that oral and IV dosing of this product, as with most opiate analgesics, is quite different. In converting an oral hydromorphone dose to IV, the generally accepted equianalgesic dose is between 3 to 1 and 5 to 1. A nurse administered 4 mg IV and the patient developed respiratory depression and became unresponsive. Two doses of naloxone IV reversed the effects of the medication. 27 Categorization of Medication Error according to the severity (cont.)
Editor's Notes
- #12 .
- #26 Wrong Dosage Form Error: The administration of a medication in a dosage form different from the one that was ordered by the prescriber. This could include crushing a tablet prior to administration without an order from the prescriber. If enteric-coated aspirin was ordered, but plain aspirin was administered, a wrong form error was counted. Wrong Time Error: The failure to administer a medication to a patient within one (1) hour from its scheduled administration time. The standard hospital administration time as approved by the Pharmacy and Therapeutic Committee is considered the reference. Administration time of a dose must not be more than 60 minutes before or after the scheduled administration time. A 30-minute window was used for medications that were ordered before, with, or after a meal. Routine administration times were obtained from each site, and times assigned on the MAR were used when no other policy was available. Wrong Drug Preparation Error: such as incorrect or inaccurate dilution or reconstitution, failure to shake suspension, crushing medication that should not be crushed, mixing drug that is physically or chemically incompatible and inadequate product packaging. Wrong Administration Technique Error: Use of an inappropriate procedure or improper technique in the administration of a drug. Examples of wrong technique error include; incorrect manipulation of inhalers, failure to maintain sanitary technique with medications, not wiping an injection site with alcohol, failure to use proper technique when crushing medications, failure to check nasogastric (NG) tube placement or flushing NG tube before and after administration of medication, failure to wash hands or improper hand washing technique used. It is defined also defined as: Exclusion of or incorrect performance of a procedure ordered by the prescriber immediately before administering each dose of medication. Examples of this error include the lack of heart rate or blood pressure measurement before giving a dose. Wrong Patient Error: such as identification not properly verified, or patients with look-alike name. Wrong Duration Error: such as not adhering to the proper schedule of administration,