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Dispensing and Administration Errors
- 1. DRUGS DISPENSING AND ADMINISTRATION ERRORS LT COL SUBHA S
- 3. CASE STUDY A 60yr old female patient was prescribed Syp. Eptoin-15ml, three times a day after craniotomy. Since Syr Eptoin was not available in pharmacy, it was substituted by another brand Dilantin. Eptoin contains (30mg/5ml of phenytoin )while Syr Dilantin contains (125 mg/5ml of phenytoin). The patient received 1025 mg of phenytoin instead of 270 mg for 5 days, this resulted in abnormal CT changes and patient remained drowsy for 7 days.
- 4. Dispensing refers to the process of preparing and giving out medicines to a patient on the basis of prescription . Dispensing error is defined as the discrepancy between the drugs prescribed, indented and dispensed. It involves the correct interpretation of the doctor’s prescription and labelling of the medicine for the use by the patient as advised.
- 5. Contd.... From the receipt of the prescription in the pharmacy to the supply of a dispensed medicine to the patient. This occurs primarily with drugs that have a similar name or appearance (LASA Drugs). Example: lasix® (frusemide) and losec® (omeprazole)
- 6. DISPENSING ERROR Dispensing Incorrect drug Dose Wrong quantity Inappropriate, incorrect or inadequate labelling Confusing or inadequate directions for use , packaging or storage. Brand substitution
- 7. HOW TO REDUCE DISPENSING ERRORS LASA drugs should be identified and updated in IP & OP frequently and information should be disseminated to all areas where drugs are used. Dispensing of drugs requires qualified and trained pharmacist. Should have good calculations and arithmetic skills, skills in assessing quality of preparations. Pharmacy should have sufficient storage and dispensing area. Compounding of drugs should be done at appropriate place. Keeping interruptions and maintaining the workload at safe and manageable level. Introducing safe systematic procedures for dispensing medicines in the pharmacy.
- 10. CASE STUDY A patient was prescribed Inj. Tramadol 100 mg , intravenously. The injection was to be diluted in 100ml of NS and to be administered over a period of 30 min. But nurse gave it as a slow intravenous injection without dilution resulting into local reaction.
- 11. RESEARCH EVIDENCES Phillips J , et al did a retrospective analysis of medication errors found that the most common types of errors were from:- Improper dose - 40.9 % Over dose – 36.4 % Wrong route – 9.5 % Wrong drug – 19 % Knowledge deficit – 44 % Communication error – 15.8 %
- 12. ADMINISTRATION ERRORS Wrong drug Wrong patient Miss doses Extra doses Less doses Incorrect rate or frequency of administration Incorrect dilution Incorrect route
- 13. CAUSES OF ADMINISTRATION ERRORS Lack of perceived risk Poor role models Lack of available technology Lack of knowledge of the preparation or administration procedures or complex design of equipment.
- 14. LEADING FACTORS Personal neglect Heavy workload Unfamiliarity with medication New staff Complicated doctor-initiated order Unfamiliarity with patient’s condition Insufficient training Physician prescribes the wrong dose Misunderstood verbal order Procedure/policy not followed
- 15. CONTRIBUTING FACTORS Failure to check the patient’s identity prior to administration Environmental factors such a noise, interruptions ,poor lighting Wrong calculation to determine the correct dose
- 16. #1 Right patient #2 Right drug #3 Right time #4 Right dose #9 Right recording #6 Right assessment #8 Right education #10 Right to refuse #5 Right route #7 Right evaluation Before administering any medication
- 17. STEPS TO BE TAKEN IN PREVENTING MEDICATION ERROR Be sure to read labels at least 3 times, before during after administration of the drug. Prepare the medicine in a well lighted room. Check the expiry date of the drug before administration. Be aware about ambiguous orders or drug names and numerical and Consult doctor if any doubt. Be alert to usually large dosage or excessive increase in dosage ordered. When in doubt, check order with prescriber, pharmacist, literature .
- 18. Contd.... Double check all calculation, even simple calculation Do not allow any other activity to interrupt your administration of medication to a client. Routinely refer to drug interaction charts or drug reference source and commit common interactive drugs to memory. Do not use any substandard abbreviation and symbols, question if any one use. Read the leaflet of the drug carefully when giving new drug first time. Do not make assumptions of illegible orders. Do not accept incomplete orders and telephonic or verbal orders. Can you read this??? Neither can we!!!
- 19. Contd.... Double check with a client who has allergies about all new drugs as they are added in treatment plan. Question a drug form used in unfamiliar way. Document all medication as soon as they are given. When you have made an error reflect on what went wrong and ask how you could have prevented the error.
- 20. Contd.... All parentral drugs prepared should be labelled prior to preparation of a second drug. General appearance of the medicines should be checked before administration. In case of injections, dilution and rate of administration should be double checked. Time started and stopped should be documented. The patient should be educated about their medications.
- 21. MONITORING ERROR Failure to review a prescribed regime for appropriateness and detection of problems , or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy is called a monitoring error.
- 22. CASE STUDY A 55 yr old female patient was admitted with the complaint of hypertension. She was prescribed Inj. Frusemide. The nurse was unable to monitor the patient carefully due to workload. The had a fall while getting up from the bed, since she developed postural hypotension.
- 23. REPORTING AND DETECTING ME “ If errors go unreported, no one benefits. If we learn about errors, we are a giant step closer to preventing them”. - (Michael R Cohen , 1999)
- 24. METHODS TO INDENTIFY ME Staff sensitization Reviewing patient’s file for medication charts , Doctor’s order sheet, progress reports. Comparing medication administration record (MAR). Discharge summaries. Patient interview Direct observation Checking the intended and dispensed medication.
- 25. ADVERSE DRUG REACTIONS Definition “It is a response to a drug that is noxious and unintended , and occurs at doses normally used in patients for prophylaxis, diagnosis or therapy of a disease. -World Health Organization
- 26. ADVERSE EVENT (AE): Any untoward medical occurrence that may present during treatment with a pharmaceutical product but which does not necessarily have a causal relationship with this treatment. Therefore, an adverse drug reaction is an adverse event with a causal link to a drug.
- 27. Drug administered Pt. develops a new condition/symptom ADE Drug suspected? Yes Check literature Documented ? (for the product Or similar class of products) Yes Highly suggestive of ADR
- 28. Not documented in literature Drug continued Drug discontinued Worsening of symptoms Symptoms improve (+ve dechallenge) Drug restarted Symptoms recur (+ve rechallenge) Any other possible causes? • Concomitant therapy • Underlying conditions
- 29. CLASSIFICATION OF ADRS Depending on…. 1.Onset of event: Acute (<60 minutes) Sub-acute (1-24 hrs) Latent (>2 days) 2. Severity: Minor Moderate Severe Lethal ADRs
- 30. Contd... 3. Type of reaction Type A (Augmented) Type B (Bizarre) Type C (Chemical) Type D (Delayed) Type E (Exit/End of treatment) Type F (Familial) Type G (Genotoxicity) Type H (Hypersensitivity) Type U (Un classified) 4.Others: Side effects Secondary effects Toxic effects Intolerance Idiosyncrasy Drug allergy Photosensitivity Drug Dependence Drug Withdrawal Reactions Teratogenicity Mutagenicity Carcinogenicity Drug induced disease (Iatrogenic)
- 31. FACTORS CONTRIBUTING TO ADRS An error in diagnosing the disease. Prescription of the wrong drug for the right disease. Prescription of the wrong dose of right drug. The drug is right for the disease but wrong for the patient due to a genetic or ethnic predisposition , age , some other illness ( like renal failure) or medication , allergy or intolerance. Noncompliance on part of patient. Self medication by the patient. Taking of many drugs(poly-pharmacy) or receiving treatment from more than one source(poly-therapy). Poor quality of pharmaceutical products.
- 32. HOW TO PREVENT ADRS Avoid inappropriate use of drugs. Use appropriate dose, route , frequency based on patient’s need. Elicit history of allergy to drugs and allergic diseases. Adopt correct drug administration technique. Appropriate laboratory test monitoring.
- 33. HOW TO DEAL WITH ADRS Be alert to even minor changes in patient’s clinical status. Listen to minor complaints. May reduce the dose or withdraw the drug after consulting the prescriber. Educate your patient. Encourage the patient to report immediately.
- 34. SUMMARY Stay alert! Question ! Learn! Don’t let it happen to you
- 35. THANK YOU