Chapter 6 Medication Safety. Learning Objectives Understand the extent and effect of medical errors on patient health and safety Describe how and to what

Chapter 6

Medication Safety

Learning Objectives

• Understand the extent and effect of medical errors on patient health and safety

• Describe how and to what degree medication errors contribute to medical errors

• *List examples of medication errors commonly seen in practice settings

• Apply a systematic evaluation of opportunities for medication error to a pharmacy practice model

• Identify the common medication error–reporting systems available

Medical Errors

• A medical error is any circumstance, action, inaction, or decision related to healthcare that contributes to an unintended health result

• Most of what is known about medical errors comes from information collected in the hospital setting– hospital data make up only a part of a much larger picture

– most healthcare is administered in the outpatient, office-based, or clinic setting

• Medical errors are difficult to define– possible causative circumstances are infinite

Medical Errors

• Medical-related lawsuits show the scope of medical errors in the United States

• One large government studied only medical errors during hospitalization– 44,000 to 98,000 people in the U.S. die each year as a

result of medical errors (greater than the risk of death from accident, diabetes, homicide, or human HIV and AIDS)

– multiple sources for potential medical errors exist

Discussion

What are some examples of medical errors?

Edited by Dr. Ryan Lambert-Bellacov

Discussion

What are some examples of medical errors?

Answer: Lab tests drawn at the wrong time (inaccurate results), major surgical errors ending in injury or death

Medication Errors

• A medication error is a medical error in which the source of error or harm includes a medication

• Like medical errors– medication errors have no specific definition because

the possible causes can be endless

– information on the effect of medication errors comes mostly from studies done in the hospital setting

• Medication-related deaths are estimated at about 7,000 each year

Medication Errors

• Fewer studies of medication errors in community practice exist– an estimated 1.7% of all prescriptions dispensed in a

community practice setting contain a medication error (4 of every 250 prescriptions)

• Not all medication errors result in harm to a patient– 65% of the medication errors detected had a meaningful

effect on the patient’s health

Medication Errors

• Measuring results of medication errors– lost lives

– disabled patients

– time lost from work or school

• cost to the healthcare system– billions of dollars – physician visits

– additional hospitalizations – emergency room visits

– admissions to long-term care – continuation of disease

Healthcare Professional’s Responsibility

• Working in healthcare means making a commitment to “first do no harm”

• The profession of pharmacy exists to safeguard the health of the public

• Healthcare must focus on treating the patient – to the best possible outcome – by the safest possible means

• No “acceptable” level of medication error exists – effect of a potential medication error on the patient cannot

be predicted– each step in fulfilling medication orders should be reviewed

with a 100% error-free goal


The only acceptable level of medication errors is zero.



• MA’s can identify potential patient sources of medication error – careful listening and observation during a patient or medical

staff interaction

– notifying the pharmacist

• MA’s make a significant contribution to patient safety – constant surveillance for potential sources of medication

error

Tips for Reducing Medication Errors

• Always keep the prescription and the label together• Know common look-alike and sound-alike drugs

• Keep dangerous or high-alert medications in a separate storage area

• Always question bad handwriting• Prescriptions/orders should be correctly spelled with

drug name, strength, appropriate dosing, quantity or duration of therapy, dose form, and route

• Use the metric system

Tips for Reducing Medication Errors

• Question uncommon abbreviations • Be aware of insulin mistakes• Keep the work area clean and uncluttered• Verify information • Labels should always be compared with the original

prescription by at least two people


If information is missing from a medication order, never assume. Obtain the missing information from the prescriber.


Tips for Reducing Medication Errors: MA’s

• Use the triple-check system • Regularly review work habits• Verify information with the patient or caregiver• Observe and listen• Keep your work area free of clutter


Patient Response

• Most patients have the intended therapeutic response expected from the medication

• Unique physical and social circumstances make it impossible to predict which– medication errors may result in no substantial harm

– may result in death

Physiological Causes of Medication Errors

• Each patient has a unique response to medication – genetically unique– speed at which medications are removed from

body varies

• Even a problem caught and corrected before harm occurs is still considered a medication error

Social Causes of Medication Errors

• Outpatients can contribute to medication errors through incorrect administration

• Social causes of error include:– failure to follow medication therapy instructions because

of cost

– noncompliance

– failure to receive therapy

– misunderstanding instructions (language barriers)



• Patients can contribute to medication errors by – forgetting to take a dose or doses

– taking too many doses

– dosing at the wrong time

– not getting a prescription filled or refilled in a timely manner

– not following directions on dose administration

– terminating the drug regimen too soon


• Social causes may result in an adverse drug reaction, or a toxic dose

• Over 50% of patients on necessary long-term medication are no longer taking their medication after 1 year

• All of these social circumstances would be considered medication errors

Categories of Medication Errors

• Possible causes of a medication error are numerous

• Categorizing errors into types aids in identification and prevention of possible causes

• Categories focus on grouping errors under a set of common definitions



• omission error: a prescribed dose is not given• wrong dose error: a dose is either above or below the

correct dose by more than 5%• extra dose error: a patient receives more doses than

were prescribed by the physician• wrong dose form error: dose form or formulation that

is not the accepted interpretation of the physician order • wrong time error: drug is given 30 minutes or more

before or after it was prescribed


• Errors can be classified by what causes the failure of the desired result

• Errors can be categorized within three basic definitions of failure:– human failure

– technical failure

– organizational failure


• Human failure is a failure that occurs at an individual level– pulling a medication bottle from the shelf based on

memory, without cross-referencing the bottle label with the medication order/prescription

– errors made by the patient such as non-compliance to prescribed drug therapy

• Technical failure is a failure resulting from location or equipment – incorrect reconstitution of a medication because of a

malfunction of a sterile-water dispenser

– failure to properly operate automated equipment

Root Cause Analysis of Medication Errors

• Root cause analysis is a logical and systematic process used to help identify what, how, and why something happened to prevent reoccurrence

• With basic principles of root cause analysis, any person can – examine his or her own work flow to determine the

opportunities for potential error

– determine what type of failure the potential error may be

– create a list of specific potential causes


• Identifying specific potential causes allows a person to take specific actions to prevent the potential error

• Actions taken improve the quality of work being done• Common causes of medication error by handlers and

preparers include:– assumption error

– selection error

– capture error


• assumption error: an essential piece of information cannot be verified and is guessed or presumed– misreading an abbreviation on a prescription

• selection error: two or more options exist, and the wrong option is chosen – using a look-alike or sound-alike drug instead of prescribed

drug

• capture error: focus on a task is diverted elsewhere and an error goes undetected– something captures the person’s attention, preventing the

person from detecting the error or causing an error to be made


Maintaining focused attention when filling prescriptions is important to avoid errors.


Prescription-Filling Process in Community and Hospital Pharmacy Practice

• Review for potential causes of medication error begins with outlining work tasks in a step-by-step manner

• Each step in this process can be a– source of medication error

– place where pharmacy personnel can correct a medication error

Prescription-Filling Process in Community and Hospital Pharmacy Practice

Each person who participates in the filling process has the opportunity to catch and correct a medication error.


Prescription-Filling Process

Outdated prescriptions should not be filled.



A prescriber’s signature is required for a prescription to be considered valid.


Prescription-Filling ProcessStep 1

• Prescribing errors include: – poor handwriting

– using nonstandard abbreviations

– confusing look-alike and sound-alike drug names

– wrong drug

– using “as directed” instructions





A leading zero should precede values less than one, but a zero should not follow a decimal if the value is a whole number. A tenfold error occurs if the decimal point is not detected.



• Opportunities for medication errors increase with the number of medications a patient takes– common with many older patients

• Profile review for every prescription should include: – check for existing allergies and multiple drug therapy

– check for drug interactions or duplication of therapy



Check the patient profile for existing allergies or possible drug interactions.


Prescription-Filling Process:Retrieve Medication

• Products can contribute to errors with – look-alike labels

– similarities in brand or generic names

– similar pill shapes or colors

• Use NDC numbers, drug names, and other information to verify selection of the correct product– use both the original prescription and the generated label

when selecting a manufacturer’s drug product from the storage shelf

– use NDC numbers as a cross-check

Prescription-Filling ProcessStep 5: Fill or Compound Prescription

• Calculation and substitution errors are sources of medication errors– write out the calculation and have a second person check

the answer

• Take care when reading labels and preparing compounded products

Medication Error Prevention

• Preventing medication errors means – carefully examining potential points of failure

– using available resources to verify information given or decisions made

• Drug identification is the most common error in dispensing and administration


Incorrect drug identification is the most common error in dispensing or administration.



• Many medication errors occur during prescribing and administration

• Prescribers are responsible for ensuring the “five Rs” or five rights– the right drug – for the right patient – at the right strength – given by the right route – administered at the right time

Innovations to Promote Safety

• The physical pharmacy work setting can have a major contribution to the overall safety of any work environment

• Automate and bar code all fill procedures• Maintain a clean, organized, orderly work area• Provide adequate storage areas• Encourage prescribers to use common

terminology and only safe abbreviations• Provide adequate computer applications and

hardware


• Innovations can minimize possibility of errors• In community pharmacy, redesigned packaging helps

patients take medication safely– Target ClearRx packaging helps patients manage their

medications• colored rings help patients identify medications intended for

each family member

• clear, easy-to-read label for patient administration instructions and cautions

• includes a pullout patient information card or printout

Learn more about the Target label design


• In hospital pharmacy, integrated computerized filling systems allow institutions to– improve efficiency

– redirect resources

Medication Error and Adverse Drug Reaction Reporting Systems

• The first step in prevention of medication errors is collection of information

• Fear of punishment is a concern with errors– people may decide not to report an error at all

– allows the same error to occur again and again

• Anonymous (no-fault) reporting systems have been established– focus on fixing the problem, not fixing the blame

State Boards of Pharmacy

• More than 20 states have mandatory error-reporting systems– most state officials admit medical errors are still under-

reported mostly because of fear of punishment

• Some states have worked to reduce the fear of reporting – allow pharmacists to document errors and error-prone

systems without worry of punishment

– most boards of pharmacy will not punish pharmacists for errors

State Boards of Pharmacy

• Pharmacy technicians are an integral part of the error identification, documentation, and prevention process

• The final and most important piece of medication error reporting is informing the patient that a medication error has taken place– commonly the task of the pharmacist

State Boards

• The circumstances leading to the error should be explained completely and honestly

• Patients should understand – the nature of the error

– what if any effects the error will have

– how they can become actively involved in preventing errors in the future

• People are more likely to forgive an honest error

Joint Commission on Accreditation for Healthcare Organizations

• Organizations can create a centralized point through which all members may channel error information safely

• The Sentinel Event Policy was created by the Joint Commission on Accreditation for Healthcare Organizations (JCAHO) in 1996

• A sentinel event is an unexpected occurrence involving death or serious physical or psychologic injury

Joint Commission on Accreditation for Healthcare Organizations

• When a sentinel event is reported, the organization is expected to – analyze the cause of the error (perform a root cause

analysis)

– take action to correct the cause

– monitor the changes made

– determine whether the cause of the error is eliminated

• Accreditation of hospitals depends on demonstrating an effective active error–reporting system

Learn more about the Joint Commission International Center for Patient Safety

Documents

Chapter 6 Medication Safety. Learning Objectives Understand the extent and effect of medical errors on patient health and safety Describe how and to what