tips to avoid medication error

1. TIPS TO AVOID
MEDICATION
ERRORS
Siti Haslinda binti Hissam
Peg Farmasi
KK Jasin

2. INTRODUCTION
WHAT IS MEDICATION
ERROR?
HOW DO MEDICATION
ERRORS HAPPEN?
TIP TO AVOID
MEDICATION ERRORS
(HEALTHCARE WORKERS)
01
02
03
04
Table of
Contents
CONCLUSION
06
TIP TO AVOID MEDICATION
ERRORS
(PATIENT/CAREGIVER)
05
2

3. Introduction
01

4. Introduction
“Making It RIGHT THE FIRST
TIME”1
4

5. 02
What is
medication

6. Medication Error
“… any preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in the control of the healthcare
professional*, patient, or consumer...”
The United States National Coordinating Council for
Medication Error Reporting and Prevention
*Professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging, and nomenclature, compounding,
dispensing, distribution, administration, education, monitoring, and use.

7. True incidents
Even simple mistake
done by healthcare staff
can lead to lethal
outcome of patient1
Any process
Prescribing, transcribing,
dispensing or
administering process
Hence, it is essential to
ensure each process is
done correctly1
Be careful!
Unclear, incomplete or
confusing presentation of
medicines information
can increase the
opportunity for health
practitioners to make
error and cause patient
harm1
Introduction
6

8. What is medication error?
2818
(2018)
↑3046
(2019)
01
02 03
Medication errors are preventable events due to the inappropriate use of
medications
If a medication error occurred, but didn’t hurt anyone, it’s called a
potential adverse drug event3
Most of the time, these errors do not cause any serious adverse outcomes2
When humans are involved, errors can happen2
At very least, it causes unnecessary discomfort or waste of money2
Some errors may be life threatening2
9

9. Medication error can happen during
any stage of patient’s care.
• Doctors
• Dentists
• MA/JM
Pharmacy
staffs
Pharmacy
staffs
• Nurse
• MA
• Caregiver

10. TOTAL MEDICATION ERROR REPORTS
(2009-2021), MOH

11. % Severity of error 2009-2020 (from total
ME)
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
0.0
20.0
40.0
60.0
80.0
100.0
120.0
96.9
91.5
78.8
82.2
86.4
93.0 94.2 93.8 94.3 95.2 95.3 96.3
3.1
8.5
21.2
17.8
13.6
7 5.8 6.2 5.7 4.8 4.6 3.7
%Near Misses %Actual Error
BAHAGIAN AMALAN DAN PERKEMBANGAN FARMASI, KEMENTERIAN KESIHATAN MALAYSIA

12. % Severity of error 2009-2020 (from total ME )
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
0.0
5.0
10.0
15.0
20.0
25.0
1.9
7.2
19.0
15.5
11.8
6.2
5.2 5.4 5.0
4.3 4.2
3.3
1.2 1.3
2.2 2.3 1.8
0.8 0.6 0.8 0.7 0.5 0.5 0.5
% Error,No Harm %Error, Harm
BAHAGIAN AMALAN DAN PERKEMBANGAN FARMASI, KEMENTERIAN KESIHATAN MALAYSIA

13. TOTAL MEDICATION ERROR REPORTS
(2017-2021), Melaka
0
1000
2000
3000
4000
5000
6000
2255
4301
4796
5217 4895
2017 2018 2019 2020 2021

14. • Near Miss (detected
before reached patient)
• Actual Error (reached
patient)
ERROR OUTCOME
CATEGORY
A,B C,D,E,F,G,H,I
* ERROR, HARM, RCA REPORTS
REQUIRED
A
Potential error, circumstances/ events have potential to
cause inciden
B Near Miss - did not reach patient
C Actual Error - caused no harm
D
Additional monitoring required to
preclude harm
E Treatment / intervention required - caused temporary harm
F Initial/ prolonged hospitalization - caused temporary harm
G Caused permanent harm
H Near death event
I Death
C L A S S I F I C A T I O N O F M E D I C A T I O N E R R O R S E V E R I T Y
Medication Error Reporting System, MOH
Harm-Temporary or permanent impairment of the
physical, emotional, or psychological function or
structure of the body and/or pain resulting there from
requiring intervention

15. Error Outcome
Category
2020
(TOTAL REPORT=
5217)
2021
(TOTAL REPORT=
4895)
2022 (Jan-Jun)
(TOTAL REPORT=
2644)
C 85 72 16
D 18 18 4
E 4 3 1
F 2 1 1
G 0 0 0
H 0 1 0
I 0 2 0
Actual Error 109 (2.1%) 97 (1.98%) 22 (0.83%)
Near Misses 5108 (97.9%) 4798 (98%) 2622 (99.2%)
ACTUAL ERROR, NEAR MISSES 2020 - 2022 in Melaka
0.1
%
0.14
%
0.08
%

16. Co ntent
(DISEMBER 2 020)
2,644/33,303 (7.9%), 2 0 2 2
NEIL
TRAN
Medication Error 2021
(KKM vs in Melaka)
Total 59,672/4,895(8.2%)
Prescribing
40,230(67.4%) /3,515 (71.8%)
Dispensing
19,001 (47.6%)/1,302(37%)
Administration
401(0.7%)/38(0.8%)
Others
272(0.5%)/40 (0.8%)
Co ntent
(1 S T
EDI TI ON ,2 012)
Co nte nt
(1S T
ED ITION , 201 6)
In which
process did
the error
occur?

17. 1*/23
0/1
0/3
0/2
F
G
H
I
ERROR WITH
HARM
(F-I)*
Jan-Jun 2022,
Melaka/KKM
*MPSG 2.0
Total
1/29*
(3.4%)
* Filling and Dispensing
*
• 11- Prescribing
• 10 - Dispensing
• 8 - Administration

18. 00
33
How do
medication
03
03

19. How do medication errors
happen?
2818
(2018)
↑3046
(2019)
01
02 03
Medication errors can happen to anyone involved in the medication use
process, in any place2
This may be due to ‘slips and lapses’ or not knowing the right thing to do2
- Poor communication between healthcare workers
- Poor communication between patients/caregivers
- Drug names that sound alike and medications that look alike
- Medical abbreviations
The most common causes of medication errors are 3
:
12

20. TIP to avoid
medication
errors (POV: healthcare
workers)
04

21. Strategies to reduce medication
errors
Minimize clutter4,8
1
• The clinic environment is often fast-
paced and intense, with high prescription
volume, insufficient staffing and
demanding patients
• Keeping COUNTERS CLEAR and CLUTTER
FREE can be challenging, but it is an
important part of reducing risk for
dispensing errors

22. Advices for a smooth flow from one task to
the next :
- To use a basket system to keep different
patients’ prescriptions and drugs separate
- To clear away the bottles from prescriptions
that have been completed
- Proper lighting
- Adequate counter space
- Comfortable temperature and humidity

23. MULTITASKING and DISTRACTION during
work is leading cause of dispensing errors
Strategies to reduce medication
errors
Reduce distraction when possible8
2
21

24. Real case example: ME due to distraction
at work
Source: CME Pembentangan Kes Kesalahan Pengubatan 2022 PKD Alor Gajah

25. Source: CME Pembentangan Kes Kesalahan Pengubatan 2022 PKD Alor Gajah

26. Workload increase is often cited as a contributing factor in
dispensing errors
Suggestions that will help reduce errors :
- sufficient staffing
- appropiate workload
- regular breaks and time off for meal breaks
- sharing responsibilities by clearly assigning duties to the staff
--> will help them understand the expectations of the flow of
work
--> may ultimately aid in reducing workplace stress
Strategies to reduce medication
errors
Focus on reducing stress and balancing heavy workloads8
3
22

27. Source: CME Pembentangan Kes Kesalahan Pengubatan 2022 PKD Alor Gajah
Real case example: ME due to peak hour

28. Real case example: ME due to peak hour
Source: CME Pembentangan Kes Kesalahan Pengubatan 2022 PKD Alor Gajah

29. For prescriptions called in by phone, it’s
important to WRITE DOWN and then REPEAT
THE ORDER TO VERIFY that it was heard
correctly
Strategies to reduce medication
errors
Verify orders4,8
4
23

30. The Joint Commission/Malaysian PAtient Safety Goals requires that AT LEAST 2
PATIENT INDENTIFIERS be used for administering medications
This strategy helps prevent medication errors due to sound-alike and look-alike
names
At this point in the process, it is also useful to have information about the patient,
such as :
- age
- allergies
- concomitant medications
- contraindications
- therapeutic duplications
Strategies to reduce medication
errors
Ensure correct entry of the prescription8
5
24

31. • MISPLACED zeros, decimal points and faulty
units are common causes of medication errors
due to MISINTERPRETATION11
• A transcription or interpretation error involving
a ZERO or a DECIMAL POINTS means :
- patient may RECEIVE AT LEAST 10 TIMES more
medication than indicated
- can result in SERIOUS CONSEQUENCES (e.g
warfarin)
Strategies to reduce medication
errors
Be careful with zeros and abbreviations8
6
25
MTF
TABLET
MMF
TABLET
MMT
SYRUP
MVT
SYRUP
VS
VS

32. Real case example: ME due to decimal
points
Enalapril
2.5mg od vs
25mg od

33. • Institute for Safe Medication Practices (ISMP) maintains
a long list of drugs with similar names that may be
confused
• Similar drug names account for one third of
medication errors
• - these types of errors are attributed to confirmation
bias9
• Can be reduced by PLACING REMINDERS on the stock
bottle/bin or in the computer system to alert staff
about commonly confused drug names10
• Routinely check all medications on the shelves and
discard any expired medications
Strategies to reduce medication
errors
Be aware of Look-Alike Sound-Alike (LASA) drugs4,8
8
27

34. Real case example: ME involving LASA
medication

35. Strategies to reduce medication
errors
Have a second pair of eyes to check prescriptions
9
One way to prevent human error is by involving a second human - a pharmacist
or technician (as permitted by state law) - in the dispensing process
When there was no one else there to check, then come back with a fresh set of
eyes
FINAL CHECKS should always include verification of the original order entry
- whether by keeping the PRESCRIPTION with the LABEL and MEDICINE
bootle/envelope until completion
- by pulling up the scanned prescription on the computer screen
28

36. Can you
guess the
medication
?
Real case example: ME

37. Filled
medication
But..this was the
actual
medication
i) Schizophrenia, other psychotic
disorder
ii) Treatment of behavioural disorders in
adults and in children
i) Major depression, obsessive-
compulsive disorder (OCD),
ii) panic disorder
iii) Social anxiety disorder (social phobia)
VS

38. Various alert strategies can be helpful, but human nature is to overlook the familiar
- LASA drugs : continue to catch the attention of staff members
- Pharmacy software system : allergy tagging, ADR history.
Strategies to reduce medication
errors
Design effective warning systems4
10
29

39. Alahan ubat-ubatan yang dimasukkan di profile Phis pesakit berjaya mengesan kesilapan pengubatan
Pesakit ada alahan terhadap ubat Non Steroidal Anti-Inflammatory Drugs (NSAIDS) diclofenac.
Pesakit telah dipreksrib dengan ubat daripada kumpulan yang sama.
Alahan telah dikesan melalui tagging pada profile Phis pesakit.
Intervensi telah dilakukan dan preksriber menukar ubat tersebut.
Real case example: Me involving drug
allergy

40. Patients are their own last of defense when it comes to medications errors
- investing a minute or 2 in speaking to them
- can reap huge dividends in catching medication errors
Basic counseling can
- help ensure that patients understand about current treatment and how to take it properly
- helps catch errors
Speaking to patients is also valuable in obtaining an accurate medication reconciliation
Strategies to reduce medication
errors
Involve the patient4,8
11
30

41. Pharmacists need to recognize their role to the patient
If receive a prescription, especially if pharmacist get to know the patients, then if something
doesn’t make sense, DON’T JUST LET IT GO!
- QUESTION the patient
- CALL prescribers to verify
Strategies to reduce medication
errors
Trust your gut4
12
31
Who can tell
the error that’s
happening
here?

42. LET’S NOT KEEP WAITING FOR THINGS TO GO
WRONG AND FIX THEM!!
Experienced staffs can sence when things are
not going right and should address those
concerns
Assist new staffs
Strategies to reduce medication
errors
Be proactive4
13
32

43.  Never assume!
It’s okay to look stupid

44. Source: CME Pembentangan Kes Kesalahan Pengubatan 2022 PKD Alor Gajah

45. Source: CME Pembentangan Kes Kesalahan Pengubatan 2022 PKD Alor Gajah

46. For RVD
For
hepatitis B

47. Source: CME Pembentangan Kes Kesalahan Pengubatan 2022 PKD Alor Gajah

48. Source: CME Pembentangan Kes Kesalahan Pengubatan 2022 PKD Alor Gajah

49. Reporting safety events-which are
classified as near-misses and errors - even
if they are your own
- to allow a big picture to develop
- so can indentify trends at the system
level
- address those issuess and encourage
peer-to-peer feedback
Strategies to reduce medication
errors
Track medication errors4
14
33

50. 05
Tips to avoid
medication errors
(POV: patient/caregiver)

51. Asking questions and understanding the answers
- Patient/caregivers should understand the nature
of the health problem, how the medicine will
respond and what result can be expected from the
medicine
- Information or drug/device counselling from
pharmacist
Ask questions from your health care
providers2
Tips to avoid medication errors
01
14

52. Strictly follow the directions
If not taken as instructed, the
medicine may not give the expected
result
Take the medications as directed2
TIP to avoid medication errors
02
15

53. Knowing medicine is one way that can
save from medication errors
- Familiarize and identify own
medication
- Medicine looks like including the
shape and colour
- Preferably learn the generic name or
active ingredient
Learn to know your medicine2
TIP to avoid medication errors
03
16

55. Look-alike
- Keep medications in original
containers
Prevent deterioration of the
medicines
- Keep all medications in a locked
cabinet (children cannot reach)
except for fridge items or away
from light
Store medications as instructed2
Tips to avoid medication errors
04
04
17

57. Real case example: Me involving wrong
administration of medicine
Source: CME Pembentangan Kes Kesalahan Pengubatan 2022 PKD Alor Gajah

58. - “Don’t ask, don’t tell” is never a smart policy when it comes to medications
and health
- Everyone involved in the medication use process have roles to play in
preventing medication errors
Conclusion
Teamwork
34

59. 1. Ministry of Health Malaysia. Quick Guide : Preventing prescription error. Putrajaya: MOH. 2020
2. Tip to avoid medication errors - PORTAL MyHEALTH (2014). www.myhealth.gov.my/en/tip-to-avoid-medications-errors
3. Medication errors: Cut your risk with these tips. mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/medication-errors/art-
20048035
4. 10 strategies to reduce medications errors. Tzipora L (2010). drugtopics.com/view/community-pharmacies-makse-care-possible-in-
medical-deserts
5. List of confused drug names: Institute for Safe Medication Practices. https://www.ismp.org/recommendations/confused-drug-names-
list. Published February 28, 2019
6. Medication Safety Self Assessment® for Community/Ambulatory. https://surveys.ismp.org/s3/Community-Self-Asssessment. Published
2017
8. Rama P.N., Daya K & Tonja M.W.10 strategies for minimizing dispensing errors. Pharmacy Times, January 2010 Aging Population,
Volume 76, Issue 1. pharmacytimes.com/view/p2pdispensingerrors-0110
9. Davis N.M. Combating confirmation bias. Am J Nurs. 1994; 94: 17
10. Kelly K. Drug-name similarities and dispensing errors. Pharmacy Times. 2005; 71: 30-31
11. Lilley L.L. & Guanci R. Careful with the zeros! How to minimize one of the most persistent causes of gross medication errors. Arm J
Nurs. 1997; 97: 14
References
35

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