1
DISPENSING ERROR
BY
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
2
DEFINITION OF MEDICATION ERRORS
• Any preventable event that may cause or lead
to inappropriate use or patient harm while the
medication is in the control of the health care
professional, patient, or consumer.
POINT OF ERRORPrescribers (doctors),Dispensers (pharmacists) Nursing staff Patient himself
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
3
TYPE OF MEDICATION ERROR
Prescribing errorOmission errorWrong time errorUnauthorized/ wrong drug errorDose errorDosage form errorDrug preparation errorRoute of administration errorAdministration technique errorDeteriorated drug errorMonitoring errorCompliance errorOther medication error
4
Types of Medication ErrorsPrescribing error
Incorrect drug product selection (based on indications, CI, known allergies, existing drug therapy), dose, dosage form, quantity, route or rate of administration, conc., or instructions for use authorised by physician; illegible Rx or med orders that lead to errors
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
5
Omission error The failure to administer an ordered dose to a patient before the next ordered dose or failure to prescribe a drug product that is indicated.The failure to administer an ordered dose excludes patient’s refusal and clinical decision or other valid reason not to administer.
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
6
Wrong time error
Unauthorized/ wrong drug error
Administration of medication outside a predefined time interval from its scheduled administration time
Dispensing or administration to the patient of medication not authorized by a legitimate prescriber
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
7
Dose error Dispensing or administration to pt of a dose that is > or< than amount ordered by prescriber or administration of multiple doses to pt
Dosage form error
Dispensing or administration to pt of a drug product in diff dosage form than that ordered by prescriber
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
8
Drug preparation error
Drug product incorrectly formulated or manipulated before dispensing or administration
Route of administration error
Wrong route of administration of the correct drug
Administration technique error
Inappropriate procedure or improper technique in the administration of a drug other than wrong route
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
9
Deteriorated drug error
Dispensing or administration of a drug that has expired or the physical or chemical dosage form integrity has changed
Monitoring error
Failure to review a prescribed regimen for appropriateness & detection of problems, or failure to use appropriate clinical or lab data for adequate assessment of pt response to prescribed therapy
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
10
Compliance error
Inappropriate patient behavior regarding adherence to a prescribed medication regimen
Other medication error
Any medication error that does not fall into one of the above predefined types
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
11
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
12
Categorizing Medication Errors• Category A – has capacity tocause error
• Category B – error occurred• Category F – error resulted intemporary harm and requiredhospitalizationbut did not reach patient
• Category C – error reachedpatient but did not cause harm
• Category G – error resulted inpermanent harm• Category H – error required
• Category D – error requiredmonitoring or intervention topreclude harm intervention to sustain life
• Category I – error contributedto or resulted in death
• Category E – error resulted intemporary harm and requiredintervention
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
13
DISPENSING ERRORS
• Errors that occur at any stage during the dispensing
process
• These errors may undermine the patient’s trust in the
pharmacist and increase the risk of litigation procedures
• Selection of the wrong strength/product.
• Mainly caused when two or more drugs have a similar
appearance or similar name (look –a-like/sound-a-like).
• Other potential dispensing errors include wrong dose,
wrong drug and wrong patient.
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
14
DRUG NAMES THAT MAY BE CONFUSED
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
15
APPERANCE CONFUSION
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
16
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
17
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
18
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
19
IMPROVE: DRUG DISPENSING
1.Use generic names as far as possible.Use furosemide (Frusemide) instead of LasixUse diclofenac instead of Voltaren.Use domperidone instead of motilium
2.Eliminate drugs with similar drug names.3.Beware of drugs with similar appearance.
Improve – drug dispensing procedure
Staff training.State the drug attributes to be checked.Drugs should be cross-checked after dispensing.Checked by the doctor before issue to patients.
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
20
MINIMIZING DISPENSING ERRORS
• Ensure a safe place for dispensing process.
• Use different brands or separate products
that look alike.
• Practice good housekeeping habits.
• Be knowledgeable of high risk drugs.
• Keep interruptions to a minimum and
maintain workload at a safe and manageable
level.
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
22
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
23
WHY REPORT MEDICATION ERRORS?
• Improve patient safety
• Development of valuable educational services
WHO SHOULD REPORT MEDICATION ERRORS?
• Pharmacists
• Nurses
• Physicians
• Other health care professionals
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
24
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
25
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
26
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
27
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences
28
CONCLUSION• Health Care professional shares the responsibility for identifying factors to medication errors and for using that knowledge to reduce occurrences.
• Medication errors cannot be ignored when they occur due to the risk of medical litigation as well as the patient’s well being.
• Medication safety solutions must be upgraded. Those who fall behind have a greater risk of patients getting seriously ill or death• Preventing Adverse Drug Events which result from errors will reduce the likelihood of them occurring.• A multidisciplinary approach to solving the problem must be promoted. • An attitude of “no blame” should be adopted.
THANK YOU