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Medication errors, which occur in the prescribing, dispensing, and administration of drugs, result in a high incidence of adverse events and significantly impact patient safety, with estimates of 44,000 to 98,000 deaths annually in the U.S. due to such errors. Factors contributing to medication errors include communication failures, workload issues, and improper training, and many errors go unreported due to perceptions of normalcy or lack of consequences. The Swiss cheese model illustrates how multiple safeguards can fail simultaneously, leading to patient risk, emphasizing the need for improved monitoring, team communication, and reporting systems to enhance safety.

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Causes & Incidence of Medication Error DR. PRABHJOT SAINI BSN MSN PhD(N) PROFESSOR & PRINCIPAL SKSS COLLEGE OF NURSING SARABHA, LUDHIANA, PUNJAB email: psaini.dr@gmail.com , skssconsarabha@gmail.com
"To Err is Human“ - but not at the cost of health of a patient.
MEDICATION ERRORS
Medication Errors: Introduction  As many as 98,000 people die in any given year from medical errors that occur in hospitals.  That's more than die from motor vehicle accidents, breast cancer, or AIDS.  Indeed, more people die annually from medication errors than from workplace injuries.
 The seriousness of medication error came to be known when Institute of Medicine (US) stated in, “To Err is Human; Building a Safer Health System,” that around 44,000 to 98,000 deaths in America occurred as a result of medical errors.  The impact of medication error on patient's well-being is unfathomable.
Most of the medication errors do not cause any harm to the patient, but there are some that cause unwarranted results, including  temporary or permanent harm to the patient's health and well-being  increased length of hospitalization  increase in cost of treatment  people losing faith in healthcare delivery system  and even deaths
 A great need to break the silence that has surrounds medical errors and their consequence. Why these mistakes happen? "How can we learn from our mistakes?"
How we define an error?  The word ERROR has drawn attention to "prevention"  According to Webster's New Collegiate Dictionary : E.g. One can make An error of omission (failure to act correctly) Or An error of commission (acted incorrectly) Error is "an act that through ignorance, deficiency, or accident departs from or fails to achieve what should be done is generally known as "the five rights": the right Drug, right Dose, right Route, right Time, and right Patient.
Overview  What is medication error?  Incidence of medication errors  Causes of medication errors  Type of Medication errors  Factors contributing to Medication errors  Dangerous abbreviations  5 ‘High alert’ medications  Possible consequences of Medication errors
“ ” What is medication error?
Medication error An error in the prescribing, dispensing, administration of a drug irrespective of whether such errors lead to adverse consequences or not.
What is medication error?  The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) has defined medication error as Thus, any medication error can be prevented before it may or may not cause harm to the patient. “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. These events may be related to professional practice, healthcare products, procedures, and systems, including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”.1
Medication error in developed countries is of PRIMARY CONCERN Medication Error is just a TERM and its significance is undervalued. Developed Countries Vs Developing Countries
Medication error: Underreported  Medication errors are routinely encountered but remain underreported.  Reporting is important to thoroughly examine their contributing factors and to implement preventive actions so as to avoid them in future from happening.
Medication error: why Underreported ?  Perception 1: it may be considered to be no one's fault (Haw, Stubbs, & Dickens, 2014) or part of normal practice (Soydemir et al., 2016). For instance, the standard time for administration of a once-a-day medication may be 8:00 a.m. at a particular institution. A nurse administers a patient's morning medications at 2:00 p.m. because the patient was away from the unit for a procedure. No medical order indicated medications should be withheld until after the procedure. Having a seemingly valid excuse for late administration of the medication does not make this any less a medication error. This error may go unreported because it is seen as a normal part of care.
Medication error: why Underreported  Perception 2: An error does not need to be reported if it does not seem to cause harm. Nurses typically do not report near misses or errors if there are no serious consequences (Hashemi, Nasrabadi, & Asghari, 2012; Kim et al., 2014; Wagner, Damianakis, Pho, & Tourangeay, 2013). In the above example, the nurse may believe no harm was done because the patient did not develop any obvious complications and so may not report this late administration as an error.
Medication error: why Underreported  Perception 3: Lack of a reporting system at an institution or lack of staff awareness that a system for reporting exists (Lederman, Dreyfus, Matchan, Knott, & Milton, 2013; Soydemir et al., 2016).  Perception 4: Fear of consequences if a medical error is reported (Almutary, & Lewis, 2012; Haw et al., 2014; Kagan & Barnoy, 2013; Yung, Yu, Chu, Hou, & Tand, 2016).
Need to be reported  The Institute of Medicine supported the concept of a culture of safety to encourage error reporting without fear of repercussion or blame Reason: So that root cause of errors could be identified and prevention measures instituted (Kohn et al., 2000).
“ ” Incidence
Incidence of medication Errors  Interesting but horrifying facts:  More people in USA die in a given year as a result of medical errors than from motor vehicle accidents , cancers or AIDS  Majority are medication errors  Indian study of paediatric intensive care unit reported 68.5% of all errors were medication errors
Incidence  Reported incidence of this iatrogenic disease related to medication error- tip of the iceberg  Difficult to determine  Few studies provide complete evaluation of errors  Different methods to detect errors  Various definitions of errors  Large volumes of medication dispensed  Annual prescriptions approx. 3.54 billion  Small % of 3.54 billion is still large number
Indian Scenario  Prof Jha reported 5.2 million medical errors take place in India annually.  The British Medical Journal quoted that India, like any other developing country, is witnessing a lot of medical errors.  The main reason being that we do not have trained doctors and nurses to measure the clinical outcomes.
Incidence  Harvard medical practice study found 19% of adverse event in hospitalized patients R/T drug complications  Error rates in outpatient pharmacies reported ~12% and in-hospital ~1 error per patient per day  19% of all doses were not administered correctly  43% of errors were due to wrong time of administration
 ~1.5 million people are harmed by medications each year  Up to 400,000 of adverse events considered preventable  Medication error studies reported different rates (underreported, different tools used)  Errors before medications reaching patient are not reported.
Causes of Medication Errors
Swiss Cheese Model  Need to identify and address the root causes of medication errors  Can be done through continuous quality improvement (CQI).  Medication error has multiple causes—a series of mistakes, oversights or system failures that combine to create risk for a patient.  This type of medication error can be visualized with the SWISS CHEESE MODEL OF SYSTEM accidents
Swiss cheese Model
What is Swiss Cheese Model?  Pictorial model for medication errors  Several slices of Swiss cheese, each represent a different layer of prescriber, pharmacist, nurse & patient related defenses or safeguards  Each layer has holes that reflect the inherent weaknesses in that particular safeguard.  Normally, if one hole is penetrated, another slice (or safeguard) stops an error in its tracks. But what if the holes suddenly lined up? Now it’s as though there are no safeguards at all.
Swiss Cheese Model
Medication error : As per Occurrence  Near Miss:  A Near-miss is an unplanned event that did not result in injury, illness, or damage but had that the potential to do so.  Did not result in patient harm, but could be categorized as near-miss  Medication incident/ Sentinal event:  An unexpected incident, related to system or process deficiencies, which leads to death or major and enduring loss of function for a recipient of healthcare services
Types of Medication Errors  Prescribing Errors (39%)  Transcription errors (12%)  Dispensing Errors (11%)  Administration errors (38%)
Causes of Medication Errors  Calculation errors  Overload  Shortage of staff  Illegible Handwriting  Misinterpretation of Prescription  Human Errors  Inappropriate use of Abbreviations  Oral/Verbal orders  Look alike Sound alike drugs  Wrong dosage calculation  Improper use of zeroes and decimals  Careless prescription  Missing information  Drug Product characteristics  Drug preparation errors  Prescription labeling  Work environment & personnel issues  Lack of concentration  Double check not possible
1. Calculation errors  Made by  Prescribers  Pharmacists  Technicians  Nurses  Pediatric population at risk- adult formulations be diluted/manipulated for peds  Personnel with multiple years of experience are just as likely to make mathematical errors as inexperienced
2. Decimal Points & Zeroes
3. Dangerous abbreviations
4. High Alert medication errors Only written orders accepted To be checked for adverse reactions
5. Prescribing errors  A clinically meaningful prescribing error occurs when, as a result of prescribing decision or prescription writing process, there is an unintentional significant reduction in the treatment being timely and effective and Increase in the risk of harm when compared with generally accepted practice It includes  Incorrect prescription #Missing information  Illegible handwriting # Use of apothecary system  Drug allergy not identified #Confusion regarding concentration of products  Irrational combinations  Out of list abbreviations  Verbal orders
Risk factors of prescribing errors  Work environment  Workload  Communication gap within team  Physical and mental well being  Lack of knowledge  Organizational factors(inadequate training)  Low perceived importance of prescribing  An absence of self awareness
6. Wrong drug & wrong route  Drug-drug interaction Warfarin prescribed to patient already on salicylate  Duplicative therapy Atenolol ordered for patient already taking metoprolol  No indication Cetrizine ordered for patient with fever  Wrong route Order of betamethazone acetate suspension ordered to be given intravenously
7.Dispensing error  Any unintended deviation among the dispensed drugs on comparison with the written medical prescription or medication order is defined as dispensing error.  The range of dispensing errors even widens in the global scenario from 0.015 to 33.5%;  4 errors per day per 250 prescriptions filled  Over 51 million dispensing errors per year
Most prevalent dispensing errors  Similar names and packaging of drugs (look alike Sound alike)  Wrong dose, wrong drug, or wrong patient  Dispensing incorrect medication, dosage, strength or dosage form  Failure to identify drug interations or contraindications  Dosage miscalculations  Illegible handwriting,  Negligence by the pharmacists  Other: Judgmental errors, increased workload, lack of supporting staff, frequent interruptions, and inadequate time to label the drugs and counsel the patients.
8.Look alike Sound alike drugs  LASA drugs are medications that look or sound similar to each other, either by their generic name, or brand name.  They might have similar packaging, similar- sounding names, or similar spellings.
Example of dispensing error
8.Illegible handwriting  The jokes about physicians and their sloppy handwriting are age-old.  But for some people it is not funny at all.  A misread prescription can lead to mistreatment and cause death.  Causes both prescription error and dispensing error  7,000 deaths annually are attributable to sloppy handwriting.  Recently in a programme on BBC : concluded that in Tamil Nadu, only one in five doctors in rural areas writes legible prescriptions
9.Verbal and telephone orders
Errors of omission & Commission
10.Drug concentration  Failure to include concentration in prescription can result in wrong dose being dispensed  E.g. •Amoxicillin suspension half tsp (2.5ml) TID •Concentration?? 1 amp or 1 vial or 1 cap UNCLEAR Order for one vial of magnesium sulphate •2ml vial (8mEq) •20 ml vial (16mEq) •10 ml vial of 50% concentration (40mEq)
11.Missing information
13. Communication failure  Failures during the process of patient management  Includes illegible handwriting, incomplete prescribing order, vague instructions, prescription not recognized & unknown prescriber  Common communication errors  Common errors include ‘g’ mistaken for ‘mg’  4 mistaken for ‘U’  Decimal point (.1 read as 1)
14.Apothecary system
15. Administration errors  Medication administration error (MAE) is defined as “any difference between what the patient received or was supposed to receive and what the prescriber intended in the original order”  It is risk areas of nursing practice while administering drugs  Majority of these errors involved either dose omissions (42%) or wrong time administration (50 %)  MAE has a significant impact on morbidity, mortality, adverse drug event, and increased length of hospital stay. Thus, it increases costs to clinicians and healthcare systems
Administration error  Incorrect administration techniques  SC administered too deep  Instilling eye drops in wrong eye  IM injection at wrong site  It involves wrong patient, wrong route of adm., wrong drug, wrong dose, wrong method, wrong time.
Causes of administration errors  Lack of knowledge on drug preparation, administration  Fail to check 5 R’s  Poor lighting  Wrong calculations to determine correct dose  Noise and interruptions
Example of administration error
17. Transcription error  Transcription error is a process of making an identical copy of prescription in the medical records. Error occurs during this process is known as transcription error.  An error that occurs during transcription of physicians order to the medication administrative record (MAR)  E.g. orders transcribed to wrong patient, wrong drug, wrong dose, wrong schedule  Contributing factors:  Incomplete or illegible nurse handwriting  Use of abbreviations  Lack of familiarity with drug names
18. Wrong time error  Wrong-time medication administration error (WTMAE) is a high risk to patient safety.  It can result in severe harm, death or fatal consequences  Standardized administration time to be followed  Acceptable interval surrounding scheduled timing WT errors are “dose administered 60 minutes before or after scheduled time”
Example for wrong time administration  A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During the admission process in the early evening, the surgical resident restarted his maintenance home medications, including oral dofetilide (an antiarrhythmic agent) taken every 12 hours. In the electronic health record, drugs ordered for "q12 hour" dosing are scheduled for 6 AM and 6 PM by default. The overnight nurse saw that the morning dose was scheduled to be given at 6 AM, but the patient was scheduled to leave for the operating room before 6 AM, so she gave the dose early, at 4 AM. During his preoperative assessment at around 6 AM, the patient was noted to have severe QTc prolongation on his electrocardiogram, putting him at high risk for torsades de pointes, a sometimes fatal arrhythmia. Considering the acute ECG changes (prior QTc intervals were normal), surgery was canceled and the electrophysiology service was consulted.
19.Deteriorated drug error  The drug to be given to patient has been unchecked or improperly stored and deteriorated prematurely at appropriate place leading to deteriorated drug error  Monitoring of expiry dates become essential  Refrigerated drugs being stored at room temperature or freezer  For example, administering insulin that has been frozen.
20.Work environment
21. Monitoring error  Failing to monitor the health status of the patient prior or post drug administration  Inadequate drug therapy review  Ordering serum drug level tests and not reviewing test results  Prescribing antihypertensive drugs and failing to monitor blood pressure  Giving antipyretics and not assessing temperature  Administering Digoxin and not monitoring pulse/ heart rate
“ ” Categorization of Medication Errors
Categorization Of Medication Errors
Summary  More people die annually from medication errors than from workplace injuries.  An error in the prescribing, dispensing, administration of a drug irrespective of whether such errors lead to adverse consequences or not.  In India, Medication Error is just a TERM and its significance is undervalued and remains unreported  Reported incidence of this iatrogenic disease related to medication error- tip of the iceberg  medication error can be visualized with the SWISS CHEESE MODEL OF SYSTEM accidents  Medication errors are descibed under prescription errors, transcription errors, administration errors  Based on the causes of errors the NCC MERP Index is formulated to categorize medication errors from Category A- I  Appropriate monitoring, good team communication, knowledgeable staff, RCA and policy on check of medication errors can reduce its incidence and make patient more safe
References 1. Duerden M, Avery AJ, Payne RA. Polypharmacy and medicines optimisation: making it safe and sound. London: King’s Fund; 2013. 2. Lisby M, Nielsen LP, Brock B, Mainz J. How are medication errors defined? A systematic literature review of definitions and characteristics. Int J Qual Health Care. 2010;22:507-18. 3. National Coordinating Council for Medication Error Reporting and Prevention. What is a medication error? New York, NY: National Coordinating Council for Medication Error Reporting and Prevention; 2015. (http://www.nccmerp.org/ about-medication-errors, accessed 19 September 2016). 4. Dean B, Barber N, Schachter M. What is a prescribing error? Qual Health Care. 2000;9:232-7. 5 Ferner RE, Aronson JK. Clarification of terminology in medication errors: definitions and classification. Drug Saf. 2006;29:1011-22. 5. IMS Institute for Healthcare Informatics. The global use of medicines: outlook through 2016. Parsipanny, NJ: IMS; 2012. 6. Inch J, Watson MC, Anakwe-Umeh S. Patient versus healthcare professional spontaneous adverse drug reaction reporting: a systematic review. Drug Saf. 2012;35:807-18. 7. GandhiTK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E., et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556-64. 8. Avery A, Barber N, Ghaleb M, Franklin BD, Armstrong S, Crowe S, et al. Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe study. London: General Medical Council; 2012. 9. Claesson CB, Burman K, Nilsson JLG, Vinge E. Prescription errors detected by Swedish pharmacists. Int J Pharm Pract. 1995;3:151-6. 10. Khoja T, Neyaz Y, Qureshi NA, Magzoub MA, Haycox A, Walley T. Medication errors in primary care in Riyadh City, Saudi Arabia. East Mediterr Health J. 2011;17:156-9. 11. Zavaleta-Bustos, Miriam, Lucila Isabel Castro-Pastrana, Ivette Reyes-Hernández, Maria Argelia López-Luna, and Isis Beatriz Bermúdez-Camps. Prescription Errors in a Primary Care University Unit: Urgency of Pharmaceutical Care in Mexico. Revista Brasileira De Ciências Farmacêuticas Rev. Bras. Cienc. Farm2008;44:115-25.
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Prabhjot Saini.pptx

  • 1.
    Causes & Incidenceof Medication Error DR. PRABHJOT SAINI BSN MSN PhD(N) PROFESSOR & PRINCIPAL SKSS COLLEGE OF NURSING SARABHA, LUDHIANA, PUNJAB email: psaini.dr@gmail.com , skssconsarabha@gmail.com
  • 4.
    "To Err isHuman“ - but not at the cost of health of a patient.
  • 5.
  • 6.
    Medication Errors: Introduction As many as 98,000 people die in any given year from medical errors that occur in hospitals.  That's more than die from motor vehicle accidents, breast cancer, or AIDS.  Indeed, more people die annually from medication errors than from workplace injuries.
  • 7.
     The seriousnessof medication error came to be known when Institute of Medicine (US) stated in, “To Err is Human; Building a Safer Health System,” that around 44,000 to 98,000 deaths in America occurred as a result of medical errors.  The impact of medication error on patient's well-being is unfathomable.
  • 9.
    Most of themedication errors do not cause any harm to the patient, but there are some that cause unwarranted results, including  temporary or permanent harm to the patient's health and well-being  increased length of hospitalization  increase in cost of treatment  people losing faith in healthcare delivery system  and even deaths
  • 10.
     A greatneed to break the silence that has surrounds medical errors and their consequence. Why these mistakes happen? "How can we learn from our mistakes?"
  • 11.
    How we definean error?  The word ERROR has drawn attention to "prevention"  According to Webster's New Collegiate Dictionary : E.g. One can make An error of omission (failure to act correctly) Or An error of commission (acted incorrectly) Error is "an act that through ignorance, deficiency, or accident departs from or fails to achieve what should be done is generally known as "the five rights": the right Drug, right Dose, right Route, right Time, and right Patient.
  • 12.
    Overview  What ismedication error?  Incidence of medication errors  Causes of medication errors  Type of Medication errors  Factors contributing to Medication errors  Dangerous abbreviations  5 ‘High alert’ medications  Possible consequences of Medication errors
  • 13.
  • 14.
    Medication error An errorin the prescribing, dispensing, administration of a drug irrespective of whether such errors lead to adverse consequences or not.
  • 15.
    What is medicationerror?  The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) has defined medication error as Thus, any medication error can be prevented before it may or may not cause harm to the patient. “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. These events may be related to professional practice, healthcare products, procedures, and systems, including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”.1
  • 16.
    Medication error in developedcountries is of PRIMARY CONCERN Medication Error is just a TERM and its significance is undervalued. Developed Countries Vs Developing Countries
  • 17.
    Medication error: Underreported Medication errors are routinely encountered but remain underreported.  Reporting is important to thoroughly examine their contributing factors and to implement preventive actions so as to avoid them in future from happening.
  • 18.
    Medication error: whyUnderreported ?  Perception 1: it may be considered to be no one's fault (Haw, Stubbs, & Dickens, 2014) or part of normal practice (Soydemir et al., 2016). For instance, the standard time for administration of a once-a-day medication may be 8:00 a.m. at a particular institution. A nurse administers a patient's morning medications at 2:00 p.m. because the patient was away from the unit for a procedure. No medical order indicated medications should be withheld until after the procedure. Having a seemingly valid excuse for late administration of the medication does not make this any less a medication error. This error may go unreported because it is seen as a normal part of care.
  • 19.
    Medication error: whyUnderreported  Perception 2: An error does not need to be reported if it does not seem to cause harm. Nurses typically do not report near misses or errors if there are no serious consequences (Hashemi, Nasrabadi, & Asghari, 2012; Kim et al., 2014; Wagner, Damianakis, Pho, & Tourangeay, 2013). In the above example, the nurse may believe no harm was done because the patient did not develop any obvious complications and so may not report this late administration as an error.
  • 20.
    Medication error: whyUnderreported  Perception 3: Lack of a reporting system at an institution or lack of staff awareness that a system for reporting exists (Lederman, Dreyfus, Matchan, Knott, & Milton, 2013; Soydemir et al., 2016).  Perception 4: Fear of consequences if a medical error is reported (Almutary, & Lewis, 2012; Haw et al., 2014; Kagan & Barnoy, 2013; Yung, Yu, Chu, Hou, & Tand, 2016).
  • 21.
    Need to bereported  The Institute of Medicine supported the concept of a culture of safety to encourage error reporting without fear of repercussion or blame Reason: So that root cause of errors could be identified and prevention measures instituted (Kohn et al., 2000).
  • 22.
  • 23.
    Incidence of medicationErrors  Interesting but horrifying facts:  More people in USA die in a given year as a result of medical errors than from motor vehicle accidents , cancers or AIDS  Majority are medication errors  Indian study of paediatric intensive care unit reported 68.5% of all errors were medication errors
  • 24.
    Incidence  Reported incidenceof this iatrogenic disease related to medication error- tip of the iceberg  Difficult to determine  Few studies provide complete evaluation of errors  Different methods to detect errors  Various definitions of errors  Large volumes of medication dispensed  Annual prescriptions approx. 3.54 billion  Small % of 3.54 billion is still large number
  • 25.
    Indian Scenario  ProfJha reported 5.2 million medical errors take place in India annually.  The British Medical Journal quoted that India, like any other developing country, is witnessing a lot of medical errors.  The main reason being that we do not have trained doctors and nurses to measure the clinical outcomes.
  • 26.
    Incidence  Harvard medicalpractice study found 19% of adverse event in hospitalized patients R/T drug complications  Error rates in outpatient pharmacies reported ~12% and in-hospital ~1 error per patient per day  19% of all doses were not administered correctly  43% of errors were due to wrong time of administration
  • 27.
     ~1.5 millionpeople are harmed by medications each year  Up to 400,000 of adverse events considered preventable  Medication error studies reported different rates (underreported, different tools used)  Errors before medications reaching patient are not reported.
  • 28.
  • 29.
    Swiss Cheese Model Need to identify and address the root causes of medication errors  Can be done through continuous quality improvement (CQI).  Medication error has multiple causes—a series of mistakes, oversights or system failures that combine to create risk for a patient.  This type of medication error can be visualized with the SWISS CHEESE MODEL OF SYSTEM accidents
  • 30.
  • 32.
    What is SwissCheese Model?  Pictorial model for medication errors  Several slices of Swiss cheese, each represent a different layer of prescriber, pharmacist, nurse & patient related defenses or safeguards  Each layer has holes that reflect the inherent weaknesses in that particular safeguard.  Normally, if one hole is penetrated, another slice (or safeguard) stops an error in its tracks. But what if the holes suddenly lined up? Now it’s as though there are no safeguards at all.
  • 33.
  • 34.
    Medication error :As per Occurrence  Near Miss:  A Near-miss is an unplanned event that did not result in injury, illness, or damage but had that the potential to do so.  Did not result in patient harm, but could be categorized as near-miss  Medication incident/ Sentinal event:  An unexpected incident, related to system or process deficiencies, which leads to death or major and enduring loss of function for a recipient of healthcare services
  • 35.
    Types of MedicationErrors  Prescribing Errors (39%)  Transcription errors (12%)  Dispensing Errors (11%)  Administration errors (38%)
  • 36.
    Causes of MedicationErrors  Calculation errors  Overload  Shortage of staff  Illegible Handwriting  Misinterpretation of Prescription  Human Errors  Inappropriate use of Abbreviations  Oral/Verbal orders  Look alike Sound alike drugs  Wrong dosage calculation  Improper use of zeroes and decimals  Careless prescription  Missing information  Drug Product characteristics  Drug preparation errors  Prescription labeling  Work environment & personnel issues  Lack of concentration  Double check not possible
  • 37.
    1. Calculation errors Made by  Prescribers  Pharmacists  Technicians  Nurses  Pediatric population at risk- adult formulations be diluted/manipulated for peds  Personnel with multiple years of experience are just as likely to make mathematical errors as inexperienced
  • 38.
  • 40.
  • 43.
    4. High Alertmedication errors Only written orders accepted To be checked for adverse reactions
  • 44.
    5. Prescribing errors A clinically meaningful prescribing error occurs when, as a result of prescribing decision or prescription writing process, there is an unintentional significant reduction in the treatment being timely and effective and Increase in the risk of harm when compared with generally accepted practice It includes  Incorrect prescription #Missing information  Illegible handwriting # Use of apothecary system  Drug allergy not identified #Confusion regarding concentration of products  Irrational combinations  Out of list abbreviations  Verbal orders
  • 45.
    Risk factors ofprescribing errors  Work environment  Workload  Communication gap within team  Physical and mental well being  Lack of knowledge  Organizational factors(inadequate training)  Low perceived importance of prescribing  An absence of self awareness
  • 46.
    6. Wrong drug& wrong route  Drug-drug interaction Warfarin prescribed to patient already on salicylate  Duplicative therapy Atenolol ordered for patient already taking metoprolol  No indication Cetrizine ordered for patient with fever  Wrong route Order of betamethazone acetate suspension ordered to be given intravenously
  • 47.
    7.Dispensing error  Anyunintended deviation among the dispensed drugs on comparison with the written medical prescription or medication order is defined as dispensing error.  The range of dispensing errors even widens in the global scenario from 0.015 to 33.5%;  4 errors per day per 250 prescriptions filled  Over 51 million dispensing errors per year
  • 48.
    Most prevalent dispensingerrors  Similar names and packaging of drugs (look alike Sound alike)  Wrong dose, wrong drug, or wrong patient  Dispensing incorrect medication, dosage, strength or dosage form  Failure to identify drug interations or contraindications  Dosage miscalculations  Illegible handwriting,  Negligence by the pharmacists  Other: Judgmental errors, increased workload, lack of supporting staff, frequent interruptions, and inadequate time to label the drugs and counsel the patients.
  • 49.
    8.Look alike Soundalike drugs  LASA drugs are medications that look or sound similar to each other, either by their generic name, or brand name.  They might have similar packaging, similar- sounding names, or similar spellings.
  • 51.
  • 54.
    8.Illegible handwriting  Thejokes about physicians and their sloppy handwriting are age-old.  But for some people it is not funny at all.  A misread prescription can lead to mistreatment and cause death.  Causes both prescription error and dispensing error  7,000 deaths annually are attributable to sloppy handwriting.  Recently in a programme on BBC : concluded that in Tamil Nadu, only one in five doctors in rural areas writes legible prescriptions
  • 58.
  • 59.
    Errors of omission& Commission
  • 60.
    10.Drug concentration  Failureto include concentration in prescription can result in wrong dose being dispensed  E.g. •Amoxicillin suspension half tsp (2.5ml) TID •Concentration?? 1 amp or 1 vial or 1 cap UNCLEAR Order for one vial of magnesium sulphate •2ml vial (8mEq) •20 ml vial (16mEq) •10 ml vial of 50% concentration (40mEq)
  • 61.
  • 62.
    13. Communication failure Failures during the process of patient management  Includes illegible handwriting, incomplete prescribing order, vague instructions, prescription not recognized & unknown prescriber  Common communication errors  Common errors include ‘g’ mistaken for ‘mg’  4 mistaken for ‘U’  Decimal point (.1 read as 1)
  • 64.
  • 65.
    15. Administration errors Medication administration error (MAE) is defined as “any difference between what the patient received or was supposed to receive and what the prescriber intended in the original order”  It is risk areas of nursing practice while administering drugs  Majority of these errors involved either dose omissions (42%) or wrong time administration (50 %)  MAE has a significant impact on morbidity, mortality, adverse drug event, and increased length of hospital stay. Thus, it increases costs to clinicians and healthcare systems
  • 66.
    Administration error  Incorrectadministration techniques  SC administered too deep  Instilling eye drops in wrong eye  IM injection at wrong site  It involves wrong patient, wrong route of adm., wrong drug, wrong dose, wrong method, wrong time.
  • 67.
    Causes of administrationerrors  Lack of knowledge on drug preparation, administration  Fail to check 5 R’s  Poor lighting  Wrong calculations to determine correct dose  Noise and interruptions
  • 68.
  • 69.
    17. Transcription error Transcription error is a process of making an identical copy of prescription in the medical records. Error occurs during this process is known as transcription error.  An error that occurs during transcription of physicians order to the medication administrative record (MAR)  E.g. orders transcribed to wrong patient, wrong drug, wrong dose, wrong schedule  Contributing factors:  Incomplete or illegible nurse handwriting  Use of abbreviations  Lack of familiarity with drug names
  • 70.
    18. Wrong timeerror  Wrong-time medication administration error (WTMAE) is a high risk to patient safety.  It can result in severe harm, death or fatal consequences  Standardized administration time to be followed  Acceptable interval surrounding scheduled timing WT errors are “dose administered 60 minutes before or after scheduled time”
  • 71.
    Example for wrongtime administration  A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During the admission process in the early evening, the surgical resident restarted his maintenance home medications, including oral dofetilide (an antiarrhythmic agent) taken every 12 hours. In the electronic health record, drugs ordered for "q12 hour" dosing are scheduled for 6 AM and 6 PM by default. The overnight nurse saw that the morning dose was scheduled to be given at 6 AM, but the patient was scheduled to leave for the operating room before 6 AM, so she gave the dose early, at 4 AM. During his preoperative assessment at around 6 AM, the patient was noted to have severe QTc prolongation on his electrocardiogram, putting him at high risk for torsades de pointes, a sometimes fatal arrhythmia. Considering the acute ECG changes (prior QTc intervals were normal), surgery was canceled and the electrophysiology service was consulted.
  • 72.
    19.Deteriorated drug error The drug to be given to patient has been unchecked or improperly stored and deteriorated prematurely at appropriate place leading to deteriorated drug error  Monitoring of expiry dates become essential  Refrigerated drugs being stored at room temperature or freezer  For example, administering insulin that has been frozen.
  • 73.
  • 74.
    21. Monitoring error Failing to monitor the health status of the patient prior or post drug administration  Inadequate drug therapy review  Ordering serum drug level tests and not reviewing test results  Prescribing antihypertensive drugs and failing to monitor blood pressure  Giving antipyretics and not assessing temperature  Administering Digoxin and not monitoring pulse/ heart rate
  • 75.
  • 77.
  • 79.
    Summary  More peopledie annually from medication errors than from workplace injuries.  An error in the prescribing, dispensing, administration of a drug irrespective of whether such errors lead to adverse consequences or not.  In India, Medication Error is just a TERM and its significance is undervalued and remains unreported  Reported incidence of this iatrogenic disease related to medication error- tip of the iceberg  medication error can be visualized with the SWISS CHEESE MODEL OF SYSTEM accidents  Medication errors are descibed under prescription errors, transcription errors, administration errors  Based on the causes of errors the NCC MERP Index is formulated to categorize medication errors from Category A- I  Appropriate monitoring, good team communication, knowledgeable staff, RCA and policy on check of medication errors can reduce its incidence and make patient more safe
  • 80.
    References 1. Duerden M,Avery AJ, Payne RA. Polypharmacy and medicines optimisation: making it safe and sound. London: King’s Fund; 2013. 2. Lisby M, Nielsen LP, Brock B, Mainz J. How are medication errors defined? A systematic literature review of definitions and characteristics. Int J Qual Health Care. 2010;22:507-18. 3. National Coordinating Council for Medication Error Reporting and Prevention. What is a medication error? New York, NY: National Coordinating Council for Medication Error Reporting and Prevention; 2015. (http://www.nccmerp.org/ about-medication-errors, accessed 19 September 2016). 4. Dean B, Barber N, Schachter M. What is a prescribing error? Qual Health Care. 2000;9:232-7. 5 Ferner RE, Aronson JK. Clarification of terminology in medication errors: definitions and classification. Drug Saf. 2006;29:1011-22. 5. IMS Institute for Healthcare Informatics. The global use of medicines: outlook through 2016. Parsipanny, NJ: IMS; 2012. 6. Inch J, Watson MC, Anakwe-Umeh S. Patient versus healthcare professional spontaneous adverse drug reaction reporting: a systematic review. Drug Saf. 2012;35:807-18. 7. GandhiTK, Weingart SN, Borus J, Seger AC, Peterson J, Burdick E., et al. Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556-64. 8. Avery A, Barber N, Ghaleb M, Franklin BD, Armstrong S, Crowe S, et al. Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe study. London: General Medical Council; 2012. 9. Claesson CB, Burman K, Nilsson JLG, Vinge E. Prescription errors detected by Swedish pharmacists. Int J Pharm Pract. 1995;3:151-6. 10. Khoja T, Neyaz Y, Qureshi NA, Magzoub MA, Haycox A, Walley T. Medication errors in primary care in Riyadh City, Saudi Arabia. East Mediterr Health J. 2011;17:156-9. 11. Zavaleta-Bustos, Miriam, Lucila Isabel Castro-Pastrana, Ivette Reyes-Hernández, Maria Argelia López-Luna, and Isis Beatriz Bermúdez-Camps. Prescription Errors in a Primary Care University Unit: Urgency of Pharmaceutical Care in Mexico. Revista Brasileira De Ciências Farmacêuticas Rev. Bras. Cienc. Farm2008;44:115-25.
  • 81.

Editor's Notes

  • #52 Primidone: anticonvulsant