by ruth kavita senior pharmaceutical technologist, knh
TRANSCRIPT
By Ruth KavitaSenior Pharmaceutical Technologist, KNH
Introduction
• Medication error is any preventable event that may cause, or has caused patient harm while the medication is in control of a health care professional (e.g. Doctor, Pharmacist, Nurse) or patient.
Medical errors are not defined as intentional acts of wrongdoing
Not all medical errors rise to the level of medical malpractice and negligence.
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Stages of medical errors
There are different stages in which a medication error can happen:
Prescribing of medicationDispensing of medicationAdministration of medication
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Prescribing stage of medicationPotential errors include:Ordering the incorrect doseOrdering the incorrect drugOrdering the wrong interval or scheduleOrdering the wrong route of administrationOrdering the wrong rateOrdering the wrong dose form (tabs, liquid)Use of abbreviations and decimal points
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Prescribing stage of medication cont’d
• Handwriting that is illegible• Incomplete orders• Ordering and not being alert to allergies• Ordering without reviewing and being aware of
current medications patient is taking resulting in adverse reactions
Wrong transcription e.g Lanoxin vs Laroxyl Wrong calculation
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Sound- alike anticancer
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Prevention of errors at prescribing stage
Educating the prescriber Educating the nurseCompleting a thorough assessment of the
patient’s history including allergies and current medications
Clarifying orders that are illegible Review by the consultant pharmacist of
medication profiles.
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Dispensing phasePotential errors include:Dispensing the wrong drug, wrong dose,
wrong quantitiesInaccurate directions for use of medicationsFailure to educate patient on use of medication Incorrect labelingDispensing an expired medication Dispensing without knowing patient allergiesDispensing to the wrong patient
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Look-alike drug labels
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Similar packaging antihypertensives
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Prevention of errors at dispensing stage
• Counterchecking dispensed medications• Checking the expiration dates on drugs• Checking the integrity of the drug• Be clear of proper use of the drug• Clear concise instructions for medication
usage • Clarifying all questionable orders• Knowing what the drug is used for • Know patient allergies
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Administration of medications stage
Potential errors include:Omitting medicationsNot shaking a medication that should beWrong storageCrushing medications not intended to be crushedUse of inappropriate diluentsAdministering the wrong medicationsIncomplete container deliveryAdsorption (container / IV sets)
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Storage of different drugs together
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Similar packaging
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Look-alike antibiotics
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Factors that contribute to the occurrence of medical errors
DistractionsStressIncreased workloadLack of educationFailure to follow policy and proceduresPoor tracking systems to identify cause and
prevention of errors
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9 “Rights” to effective prevention of medication errors
Right patient Right drugRight routeRight time Right dose Right documentationRight action Right form Right response
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Case studies- KNH 1. Findings of medication errors in oncology
pharmacy -March to December 2010 Figure 1: Type of Errors
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Case studies Cont’d
25 5 6
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19 19
2528
4851
0
10
20
30
40
50
60
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Type of error
Nu
mb
er
No Dose
BSA calculation
Wrong route
Interaction
Contraindication
Required med notprescribedWrong Medicine /RegimenPremeds missing
Lower doses
Higher doses
Frequency / duration
Figure 2: Description of prescribing errors
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2. Summary of interventions at Pharmacy 8 for the month of February, 2012
INTERVENTION ON HIGH LOW % FREQUENCY OF DOSING 17 09 45.61
DOSE 04 01 8.77 DRUG INTERACTIONS 11 19.29 DURATION OF TREATMENT - - ALLERGIES 02 3.50 CONTRAINDICATIONS 03 5.26 COMBINATIONS 10 17.54 TOTAL NO. OF INTERVENTIONS
57 100
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3. Summary of errors at IP ART Pharmacy between March and April 2014
March…………40April…………..39Most errors and omissions were related to
Age and Weight
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Way forwardStrengthen system for reporting medication
errorsComprehensive education and training of all
involved staffDifferent storage areas for important drugs
(e.g. concentrated potassium chloride)Use of technology e.g automated dispensing
cabinets, more advanced infusion devices, electronic prescribing
Increasing manpower22
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