Medication Safety & Medication Errors Part I PHCL 311 Hadeel Al-Kofide MS.c.

transcript

Medication Safety & Medication Errors

Part I

PHCL 311

Part I

PHCL 311

Hadeel Al-Kofide MS.c

Topics to be covered todayTopics to be covered today

• Introduction

• The evidence that medication error is a problem

• Definitions

• The relationship between medication error, ADE & ADE

• Classifications & types of medication error

• Reasons for medication errors

• How to prevent medication error

IntroductionIntroduction

• The goal of drug therapy is the achievement of defined therapeutic outcomes that improve a patient’s quality of life while minimizing patient risk

• With every therapy there must be a risk, it could be known or unknown

• These risks are defined as drug misadventures, which includes both adverse drug reactions (ADRs) & medication errors

DefinitionsDefinitions

• Medication error

• Adverse drug event (ADE)

• Adverse drug reaction (ADR)

Adverse Drug Events (ADE)Adverse Drug Events (ADE)

• Any injury caused by a medicine or lack of intended

medication

Adverse drug reactions & overdoses

Dose reductions & discontinuations of drug therapy

Definitions

Adverse Drug Reaction (ADR)Adverse Drug Reaction (ADR)

• Any unexpected, unintended, undesired, or excessive response

to a drug, with or without an “injury”

• Harm directly caused by the drug at normal doses,

during normal use

Definitions

Medication Error (ME)Medication Error (ME)

• Any preventable event that has the potential to lead to

inappropriate medication use or patient harm during

prescribing, transcribing, dispensing, administering,

adherence, or monitoring a drug

• Medication errors that are stopped before harm can occur are

sometimes called “near misses” or more formally,

a potential adverse drug event

Definitions

The Relationship Among ME, ADEs, & ADRs

Medication Errors ADEs

Nebecker et al. Ann Intern Med 2004;140: 795-801, J Gen Med 10:199-205,1995.

What Is The Evidence That Patient Safety Is A Problem?

Evidence That ME is A ProblemEvidence That ME is A Problem

• Medications harm at least 1.5 million people per year

• 44,000 to 98,000 hospitalized Americans die each year from

medical error

• Errors cause more death each year than breast cancer, motor

vehicle accidents & AIDS

Institute of Medicine. Preventing medication errors: quality chasm series, 2006

ME is A Problem

Evidence That ME is A ProblemEvidence That ME is A Problem

• The financial burden from these medical errors that is

estimated to be in a range of $30 billion to $130 billion

annually

• Up to 28% of these events are thought to be preventable

White TJ et al, Pharmacoeconomic. 1999, Classen DC et al, JAMA. 1997

ME is A Problem

Phillips DP. Annu Rev Public Health. 2002;23:135-50.

Deaths from Medication Errors

1983 1998

Medication Error Deaths IncreasingMedication Error Deaths IncreasingME is A Problem

Types & Classification of Medication Errors

Types & Classification of METypes & Classification of ME

• NCC MERP index for categorizing medication errors

• Medication use process

• Three major areas for medication error:

Prescribing

Dispensing

Administration

NCC MERP Index for Categorizing ErrorsNCC MERP Index for Categorizing Errors

Part II

PHCL 311

Part II

PHCL 311

Hadeel Al-Kofide MS.c

Topics to be covered last lectureTopics to be covered last lecture

• Introduction

• The evidence that medication error is a problem

• Definitions

• The relationship between medication error, ADE & ADE

• Classifications & types of medication error

• Reasons for medication errors

• How to prevent medication error

Topics to be covered todayTopics to be covered today

• Focusing on error prevention

• Identifying medication error

• How to approach error (Person Vs. System)

• Methods used to minimize or reduce medication errors

• Establishing a culture of safety (Building a safer healthcare system )

• Medication error reporting system

The Medication Use System The Medication Use System

Selection & ProcuringEstablish formulary

Monitoring Assess patient response to drug; report reactions & errors

AdministeringReview dispensed drug order; assess patient & administer

Preparing & DispensingPurchase & store drug; review & confirm order; distribute to patient location

PrescribingAssess patient; determine need for drug therapy; select & order drug

High-Level Portrayal of a Medication Use System

Clinician & administrators

Physician/ prescriber

Pharmacist Nurse/other health professionals

All practitioners, plus patient &/or family

Joint Commission. 1998

Major Areas for Medication ErrorMajor Areas for Medication Error

• Medication errors can be broadly classified as

Prescribing

Dispensing

Drug administering errors

Major Areas for Medication ErrorMajor Areas for Medication Error

38% 39%

12% 11%

Medication Errors Reporting Program US

Prescribing Errors Prescribing Errors

• It is an incorrect drug selection for a patient. Such errors can include the dose, strength, route, quantity, indication, or prescribing contraindicated drug

• This definition can be further expanded to include failure to comply with legal requirements for prescription writing

Williams DJ. 2007, Lesar et al. JAMA. 1997

Types of ME

Prescribing ErrorsPrescribing Errors

Contributing factors:

• Illegible handwriting

• Inaccurate medication history taking

• Confusion with the drug name

• Inappropriate use of decimal points

• Use of abbreviations (e.g. AZT has led to confusion between Zidovudine & Azathioprine)

• Use of verbal order

Williams DJ. 2007

Types of ME

Prescribing Errors….. Examples Prescribing Errors….. Examples

Name That Drug…

Lipitor 10mg PO QD

Filled Rx: Zyrtec 10mg

6 unties of regular insulin now

Name That Drug…

Filled Rx: 60 units

Tegretol 300mg BID

Name That Drug…

Filled Rx: Tegretol 1300mg

Cardura 2mg PO HS & Avandia 4mg PO QAM

Name That Drug…

Filled Rx: Coumadin 2mg PO HS & Coumadin 4mg PO QAM

Patient received 6mg of Coumadin PLUS no treatment for hypertension & diabetes

Prescribing Errors…..ExamplesPrescribing Errors…..Examples

Sometimes the technology itself is the problem…

Monopril 40mg

Filled Rx: Monopril 10mg

Dispensing ErrorsDispensing Errors

• It is an error that occurs at any stage during the dispensing process from the receipt of a prescription in the pharmacy through to the supply of a dispensed product to the patient

• Studies have estimated that dispensing errors occur at a rate of 1-24%

• These errors include the selection of the wrong strength/product. This occurs primarily when ≥ 2 drugs have a similar appearance or similar name (look-a-like/sound-a-like errors)

Dispensing Errors…..ExamplesDispensing Errors…..Examples

Dispensing Errors…..Examples Dispensing Errors…..Examples

Rx AXERT (almotriptan) 6.25 mg 1-2 tablets at once, & repeat in 2 hours if needed up to 25 mg/day

Dispensed ANTIVERT (meclizine)

Rx Keppra (anticonvulsant) 500 mg every 12hours

Dispensed Kaletra (antiviral)

Administration Errors Administration Errors

• Defined as a discrepancy between the drug therapy received by the patient & the drug therapy intended by the prescriber

• Drug administration is associated with one of the highest risk areas in nursing practice

Administration Errors Administration Errors

• Drug administration errors largely involve errors of omission where administration is omitted due to a variety of factors e.g. wrong patient, lack of stock

• Other types of drug administration errors include wrong administration technique, administration of expired drugs & wrong preparation administered

Administration ErrorsAdministration Errors

Contributing factors:

• Failure to check the patient’s identity prior to administration

• Storage of similar preparations in similar areas

• Noise, interruptions while undertaking a drug round, & poor

lighting

• Errors

Williams DJ. 2007

• More than one tablet for a single dose• Calculation is required to determine the correct dose

Administration Errors…..ExamplesAdministration Errors…..Examples

A patient had an epidural line for pain management & a peripheral IV line containing insulin

The nurse caring for the patient was busy & asked a second

nurse to retrieve the next scheduled epidural infusion bag

The second nurse delivered a new bag of insulin to the

patient’s bedside

Without checking the label, the primary nurse hung the insulin

infusion to the epidural line

Reasons For Medication ErrorsReasons For Medication Errors

1. Ambiguous strength designated on labels or in packaging

2. Drug product nomenclature (look-alike or sound-alike names, use of lettered or numbered prefixes & suffixes in drug name)

3. Equipment failure or malfunction

4. Illegible writing

5. Improper transcription & inaccurate dosage calculation

6. Inadequately trained personnel

7. Inappropriate abbreviations

8. Labeling errors

9. Excessive workload

10. Lapses in individual performance

11. Medication unavailable

Focusing on Error PreventionFocusing on Error Prevention

Can We Do Anything About These Errors?

Step One See the problem

Can We Do Anything About These Errors?

Step Two

Identify

The Risk

& Manage It

Identifying Medication ErrorIdentifying Medication Error

How Can We Identify The Risk?How Can We Identify The Risk?

• High alert medication

• Error prone notations

• Look-a-like & sound-a-like medications

High Alert MedicationsHigh Alert Medications

• What are high alert medications?

• How can we reduce the error associated with high alert medications?

"Top 10" Medications Involved in Drug Errors

Agent % of Drug Errors Associated with

Acute Hospital Care

Insulin 4% of all medication errors in 2005

Morphine 2.3%

Potassium Chloride 2.2%

Albuterol 1.8%

Heparin 1.7%

United States Pharmacopeia.2007

High Alert Medications

"Top 10" Medications Involved in Drug Errors

Agent % of Drug Errors Associated with

Acute Hospital Care

Vancomycin 1.6%

Cefazolin 1.6%

Acetaminophen 1.6%

Warfarin 1.4%

Furosemide 1.4%

United States Pharmacopeia.2007

Strategies To Reduce Risk From High-Alert Medications

• Limit the access to these medications

• Standardizing the ordering/preparation & administration

• Independent double check at dispensing & administrating phase

Error-Prone NotationsError-Prone Notations

• Ambiguous medical notations are one of the most common & preventable causes of medication errors

• Misinterpretation may lead to mistakes that result in patient harm

• Delay start of therapy due to time spent for clarification

Implement “Do Not Use” ListImplement “Do Not Use” List

• ISMP & FDA recommend that ISMP’s list of error-prone abbreviations be considered whenever medical information is communicated

ISMP= Institute for Safe Medication Practices, FDA= Food and Drug Administration

Complete list is located at:

www.ismp.org/Tools/errorproneabbreviations.pdf

Error Prone Notations

Short List of Error-Prone Notations*Short List of Error-Prone Notations*

** Comprises “Do Not Use” list required for JCAHO accreditation Comprises “Do Not Use” list required for JCAHO accreditation

Notations should NEVER be usedNotations should NEVER be used

Notation Reason Instead Use

U Mistaken for 0, 4, cc Unit

IU Mistaken for IV or 10 Unit

QD Mistaken for QID Daily

QOD Mistaken for QID, QD “every other day”

Trailing zero

(X.0 mg)

Decimal point missed “X mg”

Naked decimal

Point (.X mg)

Decimal point missed “0.X mg”

cc Mistaken for U “mL”

MS Can mean Morphine Sulfate

or Magnesium Sulfate

“Morphine Sulfate”

> or < Mistaken as opposite of

intended

“greater than” or

“less than”

μ Mistaken for mg “mcg”

@ Mistaken for 2 “at”

/ Mistaken for 1 “per”

+ Mistaken for 4 “and”

D/C, dc, d/c Misinterpreted as when Misinterpreted as when

“discontinued” followed by “discontinued” followed by

list of medicationslist of medications

“discharge”

“discontinued”

Error-Prone Notations…..Examples Error-Prone Notations…..Examples

Intended dose of 4 units

Administered 44 units

Should be written as “4 units”

Error-Prone Notations…..Examples Error-Prone Notations…..Examples

Administered 4mg

Should be written as “0.4 mg.”

Intended dose of “.4 mg”

Strategies To Reduce The Risk From Error Prone Notations

• NEVER use notations

Approaches to Reduce Medication Errors

• Person-centered approach

• System centered approach

• The Swiss cheese model of systems errors

Person-Centered Approach

• It has been traditional used in analysis of medication errors

• It looks at medication errors as occurring due to human frailty, including

Forgetfulness

Poor motivation

Carelessness, not paying attention

Negligence

System-Centered Approach

• Errors expected to occur

• Errors are viewed as the end result & not the cause

• There is potential for error & recurring errors in every system, & even the best systems fail

System-Centered Approach

• Solutions are based on the belief that conditions can be changed, rather than focusing on changing humans

• Barriers & safeguards should be implemented to help prevent errors

• It is essential to focus on how & why the system failed & not on which individual failed

Methods Used to Minimize or Reduce Medication Errors

Reducing Medication ErrorReducing Medication Error

• Steps to minimize medication error

• Prescriber actions

• Pharmacy (dispensing) actions

• Nurse (administrator) actions

Steps to Minimize Medication ErrorSteps to Minimize Medication Error

Mosteffective

Leasteffective

Forcing functions & constraints

• Use pharmacy system that will not fill any order unless allergy information, patient weight & height are entered

• Use computer order entry with dosage checks

• Remove dangerous IV drugs (e.g. conc. potassium, hypertonic sodium chloride) from ward stock

• Limit choices of available drugs in pharmacy

• Limit dosage strengths & concentration for each drug

• Mix IVs in the pharmacy

Automation & computerization (Reduce reliance on memory)

• Use drug-drug interaction checking system

• Use computerized order entry

• Use computerized patient information

• Use bar-coding on drugs, containers, medication records, patient wristbands

• Automated dispensing on patient care unit

Standardization & protocol

• No error –prone abbreviations

• Use generic names rather then brand name

• Use standard equipment—one kind of pump or syringe

• Use protocol for complex medication administration e.g. heparin, chemotherapy

Prescriber Action to Reduce MEPrescriber Action to Reduce ME

• Stay current & knowledgeable concerning changes in medication & treatment

• Utilize pharmacist consultation if available

• Ensure that drug orders are complete, clear, unambiguous & legible

Including patient weight, dosage (mg/kg/dose or/day), frequency & route of administration

Avoid use of terminal zero e.g. use 5 rather 5.0

Use a zero to the left of a zero ( use 0.2 rather .2 )

• Discuss medication changes with nursing & other staff & families

Pharmacy Action to Reduce MEPharmacy Action to Reduce ME

• Independent double check orders both on calculation & preparation

• Clarify confusing orders

• Checking for current patient drug allergy

• Dispense medication using unit-dose, ready to administration form whenever possible

• Patient name, generic drug name, patient specific dose on all labels

Nursing Action to Reduce MENursing Action to Reduce ME

• Double check medication calculations

• Verify drug order & confirm patient identity & weight before administration

• Have access to drug information on all medications

• Familiar with the operation of medication administration device

Medication Error Reporting Systems

Medication Error Reporting SystemMedication Error Reporting System

• International systems

• National system

• Local (in hospital or healthcare setting) system

• No system

International SystemsInternational Systems

• The Medication Error Reporting Program operated by United States Pharmacopoeia in cooperation with the ISMP

• The Joint Commission on Accreditation of Healthcare Organization (JCAHO) sentinel event reporting system

• The FDA MedWatch program

• MEDMARX®

• The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

PharmacovigilancePharmacovigilance

• Data gathering related to the detection, assessment, understanding, and prevention of adverse events

• Identifying new information about hazards associated with medicines, preventing harm to patients

• Medical errors are broader category which includes adverse reactions but also other factors (diagnostic errors, equipment failure, nosocomial infections ... )

The Role of Pharmacists in Medication Error PreventionThe Role of Pharmacists in

Medication Error Prevention

How Can Pharmacists Reduce ME?How Can Pharmacists Reduce ME?

• Clinical pharmacist

• Drug & poison information pharmacist

• Staff pharmacist

• Medication safety pharmacist??

Pharmacist on Patient-Care TeamPharmacist on Patient-Care Team

• A full-time unit-based clinical pharmacist substantially decreased the rate of serious medication errors in ICU by 66%

• Studies shows that clinical pharmacy services & increase hospital pharmacy staffing are associated significantly with reduction in medication errors

Leape LL et al. JAMA.1999, Kaushal R et al. American Journal of Health-System Pharmacy.2008

Clinical Pharmacy & ME Reduction Clinical Pharmacy & ME Reduction

• Drug histories

• Drug information services

• Adverse drug reaction monitoring

• Drug protocol management

• Medical rounds participation

Bond CA et a. Pharmacotherapy.2002

Always remember

“to Err is Human!”

Medication Safety & Medication Errors Part I PHCL 311 Hadeel Al-Kofide MS.c.

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