Errors are every doctor's nightmare. Adverse drug events are the most common error in hospitals, especially in intensive care units, emergency rooms, operating theaters, and at night. Reducing errors requires improving various aspects of the medication system such as computerized physician order entry, unit dose packaging, automated dispensing, bar code scanning, look-alike/sound-alike drug names, administration processes, intravenous medications, and health information technology alerts. A systems approach is needed to redesign processes and implement checks, rather than blaming individuals, in order to significantly reduce medication errors.

2. Errors are every doctor’s nightmare !

4. ADE = Adverse drug events
• Most common error in hospital
• Especially common in certain
settings
–ICU
–ER
–OT
–Night-time

5. Weak links

6. 6
Can you read this?
Neither can we!

7. Computerized physician order entry
( CPOE) system
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8. Reducing dispensing
errors
• Unit dose medication dispensing
• Automated medication dispensing
system
• Bar code medications for dispensing &
administration (patient given barcoded
wristband)
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9. LASA - Look Alike Sound Alike
• Confusing drug names is one of the most common
causes of medication error
• With thousands of drugs currently in market,
potential for error is significant
• Contributing factors are
– illegible handwriting,
– incomplete knowledge of drug names
– similar packaging or labelling
– similar clinical use
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11. LASA drugs
• 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
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12. Reducing administration errors
• Check patient’s identity
• Dosage calculations cross checked
• Ensuring medication given at correct
time
• Minimizing interruptions during drug
rounds
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13. Reducing IV Medication Errors
• Incidence of errors
with injectable
medications is higher
than with other
forms of medications
• Half of all harmful
medication errors
originate during drug
administration step
Taxis K, Barber N. Ethnographic study of the incidence and severity of intravenous medicine errors. Br Med J. 2003;326:684-7.
Cousins DH, Sabatier B, Begue D, et al. Medication errors in intravenous medicine preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care.
2005;14:190-5.
Bates D, Spell N, Cullen DJ, et al. The cost of adverse events in hospitalized patients. JAMA. 1997;227:307-11.
Bates DW, Cullen DJ, Laird N. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274(1):29-34.

15. Infusion systems provide a unique protection
against medication errors
The many available options differ in the respective complexity and
number of steps required to prepare the solutions and in the
opportunities for potential contamination
Ready to useReady to mixManual admixture
Open
containers
Closed
containers
Ready to useReady to mixManual admixture
Open
containers
Closed
containers
BSI Risk
Med. Error Risk
HIGH LOW
HIGH LOW

16. Role of doctors
• Specify dosage form, drug strength & complete
directions on prescriptions
• Double-check doses and brand names
• Use both brand name & generic name on
prescription
• Legible handwriting in CAPS
• Respect nurses
• Respect patients
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17. 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
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18. Role of nursing staff
• Most errors do not reach patient because of
barrier role played by a nurse
• Independent calculations of paediatric doses
by more than one person
• Development of standardized dose & rate
charts for products such as vasoactive drugs
• Ask for help if you are unsure
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19. Role of the patient
• Last line of defence - patients ( and their
caregivers)
• Listen to the patient !
• Followup !

20. Role of pharma
• Pre-market testing of brand names to
reduce the risk of “sound-alike” drugs
• Clearer labeling to prevent the problem
of “look-alike” drugs
• Developing safer tamper-proof
packaging
• Effective post-marketing surveillance to
identify potentially harmful situations

21. Role of pharma
• Integrate with digital ecosystem
• “ Smart “ pill dispensers with embedded IoT
• Medication reminders are valuable for
patients
• “Beyond the pill “ model, to engage directly
with patients . Value add services to help
patients manage their illness better
• Create grateful customers for life

22. Pharmacovigilance
• The National Pharmacovigilance Program is in the
Central Drugs Standard Control Organization,
New Delhi.
• The US FDA is a world leader. The FDA
MedWatch program at
http://www.fda.gov/Safety/MedWatch/ provides
for clinically important safety information.
• US-headquartered, ISMP (https:/www.ismp.org/)
is respected worldwide as the premier resource
for disseminating accurate medication safety
information.

23. When an error occurs
• Patient safety becomes the top priority
• The nurse assesses the patient and
notifies the doctor
• Once the patient is stable , report the
incident to the nursing supervisor
• All medication errors include near misses
should be reported as part of risk
management

24. Is this what you do in real life ?

25. Problems with reporting
• Most medication errors are not reported
• Numbers reported are misleading
 Only small percentage detected
 Focus on errors of commission ( errors of
omission ignored)
 Medical staff is scared to report
 Doesn’t think it’s their job to do so
 Reporting is seen as pointless,
cumbersome and time-consuming

27. Pass the buck

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31. Nursing Challenges
• Not enough time
• Lack of training
• Excessive
workload
• Bossy doctors

32. Post-operative pain

34. Systems, Not People
• Medication errors are a property of the
system as a whole , rather than simply
results of the acts or omissions by the
people in the system
• Performance improvement requires
changing the system, not changing the
people
– Practitioners are held to an unattainable
standard—perfection

35. System changes?

36. 1. Patient information
2. Drug information
3. Communication related to medications
4. Drug labeling, packaging, and nomenclature
5. Drug standardization, storage, and distribution
6. Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
10 Key Elements of the Medication
System

37. Make the system safer !
• Automate when appropriate
• Standardize – reduce reliance on memory
• Use checklists & standard operating procedures (SOPs)
• Simplify by reducing the number of steps and handoffs
• Add redundancy (double checks) for high-risk processes
to create a safety net
• Improve teamwork and communication
• Stress-test the system, and try to break it, to find out the
“failure points” so that these can be reduced and
removed

38. Positive Safety Culture
• Provide leadership – driven by the CEO
• Open Culture
• Just Culture
• Reporting Culture
• Learning Culture
• Promote effective team functioning
• Anticipate the unexpected
– Design for recovery

39. Accountability in Systems
• A nonpunitive, system-based approach
to error reduction does not diminish
accountability; rather, it redefines
accountability and directs it in a
productive and useful manner

40. Health IT as a safeguard
• EMRs and HIS can help reduce medical
errors by using artificial intelligence .
• For example, automatic alerts can be
triggered when there is a possible toxic
drug interaction, and the doctor is
“reminded” about these risks, thus
reducing the potential for errors.

41. CIMS drug database - comprehensive source of locally approved drug
information
CIMS decision support modules
CIMS INTEGRATED provides real-time interactivity and intervention checks for
doctors and pharmacists, improving medication management at the point of
care. Modules
 Drug Information
 The DrugInfo* module delivers timely regularly updated prescribing information on pharmaceutical
products. This module comprises of CIMS Essential Product Information and Generic Monograph
and also provides list of local Brands and Global generics data.
 Drug Alert
 The DrugAlert module processes drug-drug interaction checks. An interaction warning
displays essential information after checking for an interaction between two drugs.
 Drug Allergy Alert
 The DrugAllergyAlert module enables the healthcare professional to process drug allergy
checks at the point of care by comparing a patient’s drug allergy profile and the current medication
regime, against the active ingredients in the medications about to be ordered.
 Drug Health Alert
 The DrugHealthAlert module is used in conjunction with the patient’s profile for stored
medical conditions and subsequently for potential contraindications with the prescribed
medication. The database currently supports ICD10.
CIMS INTEGRATED Modules

42. DrugHealth Alert Sample via HIS

44. Overall Hospital Workflow

45. Drug Distribution Practices
• Unit-dose system
• Computer-generated labels
• Automated dispensing equipment
• Secure drug storage

47. Medication reconciliation
• When patient is shifted from ICU to ward –
increased scope for errors

49. Problems with Health IT
• When one introduces a technology to reduce
one kind of error, one introduces the
possibility of new kinds of error. Multitasking
is a misnomer
• Performance degrades when clinicians try to
do several things simultaneously, because of
the cognitive trap of inattentional blindness
(focusing so much on one thing that they miss
another).

51. While these alerts can be life-saving, one of the
great challenges of these clinical decision
support systems (CDSS) has been alert fatigue,
as clinicians tire of being repeatedly
bombarded by electronic warnings, and start
to ignore the important ones, thus allowing
errors to creep in.

52. Hospitals are high complexity zones

53. The best technology to prevent
errors ?
• EMR
• Bar coding
• RFID – Radiofrequency identification
• Blockchain
• IoT
• Beacons

55. Humans as heroes
• Respect the front-line staff – doctors, nurses
and pharmacists. They are the real-life experts
• Ask them what you can do to help them do
their work safely
• Entropy - natural tendency for
things to go wrong.
• Safety is a dynamic non-event.
• Hard work to achieve this

56. Humans as heroes
• Humans cause problems – but they are the
solution as well.
• Inspite of the chaos and constraints under
which hospitals function, the staff still delivers
safe care to their patients most of the time.
• Their adaptability, foresight and resilience is a
shield against errors.

58. • Sadly, today the clinical staff’s skills
are wasted on paperwork

60. www.thebestmedicalcare.com
Dr Aniruddha Malpani