In the name of Allah, Most Gracious, Most

Merciful.

STRATEGIC PLAN TO MINIMIZE

MEDICATION ERRORBy

Mr.Jawed Ali Quazi

OUR GOALS FOR TODAY

Define medication errors and classify their significance

Understand the extent of medication errors and their impact on patient care

Discuss the many factors that contribute to errors and the impulse to “place blame” on healthcare workers

Examine approaches to minimize the risk of medication errors

DEFINING MEDICATION ERRORS

"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to:

National Coordinating Committee-Medication Error Reporting and Prevention (NCC MERP); accessed at http://www.nccmerp.org/aboutMedErrors.html; Jan. 2012.

• professional practice• health care products• procedures and systems• product labeling, packaging, and nomenclature

• dispensing• distribution• administration• education• monitoring

Medication Errors in 1,116 Hospitals

Medication Error (Overall)

430,586

5.07% (of admission)

1 error every 22.7 hr

1 every 19.7 admission

found 616 medication errors (5.7%), 115 potential ADEs (1.1%), and 26

ADEs (0.24%). Of the 26 ADEs, 5 (19%) were preventable.

Most potential ADEs occurred at the stage of drug ordering (79%)

The rate of potential ADEs was significantly higher in neonates in the neonatal intensive care unit.

Ref: JAMA. 2001;285(16):2114-2120. doi:10.1001/jama.285.16.2114

Reviewed 10 778 medication orders

IF YOU SAW THIS, WOULD YOU FLY ?

Extra ExtraAirlines expect 1-2jets to crash daily

Over 1000 deaths expected weekly

BUY WHAT ABOUT BEING A PATIENT IN THE HEALTH CARE SYSTEM

Kohn et al. Committee on quality health care in America. IOM. Academy Press. 1999.

Extra ExtraAirlines expect 1-2 jets to

crash daily

Over 1000 deaths expected weekly

=44,000 – 98,000deaths annually

due tomedical errors

A Comparison of Risks

Risk (per flight) of dying in a commercial airline accident 1 in 8 million*

Risk (per hospital admission) of dying from a medical error >1 in

1,000

*1 in 2 million from 1967-1976

Accidents123,706

MedicalErrors

~100,000

Alzheimer's74,632

Diabetes71,382

www.cdc.gov/nchs/fastats. Accessed Jan 2012. Based on 2007 data.

How medical errors rank as cause of mortality

Heart616,067

Cancer562,875

Stroke135,952

Lung127,924

NCC MERP. accessed Jan 2012. www.nccmerp.org

Classifying medication errors

A circumstances exist for potential errors to occur

B an error occurred but did not reach the patient

C error reached the patient but did not cause harm

D patient monitoring required to determine lack of harm

E error caused temporary harm and some intervention

F temporary harm with initial or prolonged hospitalization

G error resulted in permanent patient harm

H error required intervention to sustain the patient’s life

I error contributed to the patient’s death

TYPES OF MEDICAL ERRORS

Surgical Errors 47.7%

Wound Infections,

13.6%

Surgical Failure, 3.6%

Mistakes during

Surgery, 12.9%

Mistakes discoveredLater, 10.6%

Others 7%

NON-SURGICAL ERRORS 52.3%

Medication Errors

19.4%

Diagnostic, 8.1%

Therapeutic, 7.5%

Procedure

Related, 7%

Others,10.3%

MEDICATIONERRORS (20%)

Ordering/ Prescribing

39%Administrati

on 38%

Dispensing 12%

Transcribing 11%

Some reasons errors occur

• poor communications within healthcare team• verbal orders

• poor handwriting• improper drug selection• missing medication• incorrect scheduling

• look alike / sound alike drugs

• polypharmacy

• availability of floor stock (no second check)• drug interactions

• hectic work environment• lack of computer decision support

CAUSES OF MEDICATION ERRORS Calculation errors Improper use of zeros & decimal points Inappropriate use of abbreviations Careless prescribing Illegible handwriting Missing information Drug product characteristics Compounding /drug preparation errors Prescription labeling Work environment & personnel issues Deficiencies in medication use systems

Medication Errors, Who Makes Them?

Physician

Pharmacist Nurse Patient

Any member of the health care team

MEDICATION ERROR REPORTS FOR LAST TWO YEARS

Month 1

Month 2

Month 3

Month 4

Month 5

Month 6

Month 7

Month 8

Month 9

Month 10

Month 11

Month 12

0

100

200

300

400

500

600

700

432

509

432

599555

432

338

444

376400

326300

338

462449

397379

300288309314

282322335

1434

1435

QUARTERLY MEDICATION ERROR DEPT WISE

Medica

l

Surgic

alOrth

oCh

est

Cardi

ology EN

T

Ophtha

lmolo

gyPea

dia

Urolog

y

Dermato

logy

AKU

Emerg

ency

OBG/LR

Dental

Neurol

ogy

Psychi

atric c

linic

0

20

40

60

80

100

120

140

160

180

Series1

MEDICATION ERROR MOST COMMON TYPE

No Diagnosis Prohibited Abbr No Gen Name Prescription Previlage

No.file No. weak strenght 0

20406080

100120140160180

Series1

MOST COMMON ERROR TOTAL NO. OF ERROR QUARTERNo Diagnosis 148Prohibited Abbr 80No Gen Name

168Prescription Previlage 57No.file No. 98Weak Strength 57

PREGABALIN (LYRICA)An anticonvulsant approved in Canada and the US since2005 to treat neuropathic pain approved by the European Commission in 2006 to treat generalized anxiety disorder. The maximum dose of pregabalin depends on its indication but should not exceed 600 mg/day.

PREGABALIN (LYRICA)Clinical studies including 5500 patients showed that euphoric effects were reported more frequently in pregabalin groups versus placebo (4% vs. 1%, respectively).A clinical abuse liability study found that pregabalin had a potential for euphorigenic activity in susceptible populations.Therefore scheduled by the US Drug Enforcement Administration under the Controlled Substances Act as a Schedule V drug, indicating that it had abuse potential.

Emerg Med J 2013;30:874 doi:10.1136/emermed-2013-203113.20 •Abstracts

Lyrica Nights–recreational Pregabalin Abuse In An Urban Emergency DeptAuthor Affiliations1.Emergency Department, Royal Victoria Hospital, Belfast, United Kingdom

"Pregabalin Abuse, Dependence, and Withdrawal: A Case Report." The American Journal of Psychiatry, 167(7), p. 869

ROOT CAUSE ANALYSISNo Medical Reconciliation

Computer Operated Entry

Hospital File Number

Prescribing Privilege

MEDICAL RECONCILIATIONReconciliation: A process of identifying the most accurate list of all medications a patient is taking—including name, dosage, frequency, and route.Requires comparing the patient’s list of current medications against the physician’s admission, transfer, and/or discharge ordersNeeds even for OPD patients by MOH

http://www.ihi.org/NR/rdonlyres/598D427A-4BDA-419D-91B5-B836D23A6F1D/0/CampaignOverview101105.ppt#358,9,Prevent Adverse Drug Events by Implementing Medication Reconciliation

ZANTAC (Ranitidine 150mg)

ZINNAT (Cefuroxime 250mg tablet/ susp )

Generic NameDiagnosis

IMPACT ON PATIENT Factors:

health status of patientsmagnitude of overdosedamage as result of omission

Financial Implicationsprolong hospital stays & increase health

care expenses estimated to cost billions of dollars annually

additional medical management

Sources of Error• Prescribing error - selecting the wrong or

inappropriate drug/dose/formulation/duration etc• Communicating those instructions• Supply error - timely; wrong drug, dose, route;

expired medicines, labelling.• Administration error - timing; wrong route; wrong

rate/technique.• Lack of user education - actions to take.

MEDICATION ERRORPREVENTION

Prescribers

Avoid illegible Handwriting

Minimize Telephone & Verbal orders

Document Drug Allergies

Familiar With medication

Order system

Update drug knowledge

WRITE CLEARLY

MISTAKE IDENTITY

DANGEROUS ABBREVIATIONS “AZT” for zidovudine (Retrovir)

could be azathioprine (Imuran) “U” HAS been mistaken for “zero”(o)

10 U insulin order & patient received 100 insulin units

“QD” has been read as “QID” or “OD” DO NOT USE Lists

The Joint Commission Institute for Safe Medication Practices (ISMP

DECIMAL POINTS & ZEROS Decimal point errors cause significant

consequences Decimal point errors occur

result of miscalculationwhen writing orders or instructions result of artifact on faxed order

Always write leading zero in front of number < 1

Never write trailing zeros

SOLUTION: ENHANCE TECHNOLOGY INTERVENTIONS

e-Prescribing Systems: Reduced medication errors by 85% Net cost savings of $403,000 in ambulatory care settings22,23

Bar Code Electronic Medication Administration System (eMAR) Technology: 51% reduction in medication errors Annual savings of $2.2 million in a large academic

hospital24,25• Computerized Physician Order Entry (CPOE):– Reduced serious medication errors by

81%26

Notes22. Kaushal, R., Kern, L.M., Barrón, Y., et al. (2010). Electronic prescribing improves medication safety in community-based office practices. J Gen Intern Med, 25(6), 530-536.23. Weingart, S.N., Simchowitz, B., Padolsky, H., et al. (2009). An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care. Arch Intern Med, 169(16), 1465-1473.24. Poon, E.G., Keohane, C.A., Yoon, C.S., et al. (2010). Effect of bar-code technology on the safety of medication administration. N Engl J Med, 362(18),1698-1707.25. Maviglia, S.M., Yoo, J.Y., Franz, C., et al. (2007). Cost-benefit analysis of a hospital pharmacy bar code solution. Arch Intern Med, 167(8), 788-794.26. Bates, D.W., Teich, J.M., Lee, J., et al. (1999). The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc, 6(4), 313-321.

Clinical Effectiveness of Safe PracticesIntervention Results

Physician computer order entry 81% reduction of medication errors

Pharmacist rounding with team 66% reduction of preventable adverse drug events; 78% reduction of preventable adverse drug events

Rapid response teams Cardiac arrests decreased by 15%

Team training in labor and delivery 50% reduction in adverse outcomes in preterm deliveries

Reconciling medication practices upon hospital discharge

90% reduction in medication errors

DRUG CONCENTRATION Failure to include concentration in

prescription can result in wrong dose being dispensedamoxicillin suspension 1/2 tsp (2.5 mL) TID Concentration?

“1 amp,” “1 vial,” “1 cap” unclearmultiple strengths, doses, or vial sizes

Order for one “vial” of magnesium sulfate?2 mL vial (8 mEq)20 mL vial (16 mEq)10 mL vial of 50% concentration (40 mEq)

ILLEGIBLE HANDWRITING Handwriting of physicians is subject of

jokesno laughing matter

Unclear orders should be clarified Use standardized, preprinted order

forms Computer generated & typewritten

labels Use of upper- and lowercase lettering

(TALLman)

MISSING INFORMATION Lack of medical information about

patient may cause errorage weight allergies diagnosis indication & severity of condition

HUMAN ERROR(MISTAKES, SLIPS, LAPSES)

Error is inevitable due to “our” limitations:- limited memory capacity- limited mental processing capacity- negative effects of fatigue other stressors

We all make errors all the time Patients suffer adverse events much more

often than previously realised Errors often NOT immediately observed

CONCLUSIONS Human beings will always make errors

Errors are common in medicine, killing tens of thousands

Naming, blaming and shaming have no remedial value

THANK YOU