how to minimize medication error

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In the name of Allah, Most Gracious, Most Merciful.

Author: jawed-quazi

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Slide 1

In the name of Allah, Most Gracious, MostMerciful.

STRATEGIC PLAN TO MINIMIZE MEDICATION ERRORByMr.Jawed Ali Quazi

Our goals for todayDefine medication errors and classify their significanceUnderstand the extent of medication errors and their impact on patient careDiscuss the many factors that contribute to errors and the impulse to place blame on healthcare workersExamine 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

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

If you saw this, would you fly ?

Extra Extra

Airlines 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 Extra

Airlines expect 1-2 jets to crash daily

Over 1000 deaths expected weekly

=44,000 98,000deaths annuallydue tomedical errors

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.orgClassifying medication errorsA circumstances exist for potential errors to occurB an error occurred but did not reach the patientC error reached the patient but did not cause harmD patient monitoring required to determine lack of harmE error caused temporary harm and some interventionF temporary harm with initial or prolonged hospitalizationG error resulted in permanent patient harmH error required intervention to sustain the patients lifeI error contributed to the patients death

Types of Medical Errors

Non-Surgical Errors 52.3%

MedicationErrors (20%)

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 ErrorsCalculation errorsImproper use of zeros & decimal pointsInappropriate use of abbreviationsCareless prescribing Illegible handwritingMissing informationDrug product characteristicsCompounding /drug preparation errorsPrescription labelingWork environment & personnel issuesDeficiencies in medication use systems

Medication error reports for last two years

Quarterly Medication Error dept wise

MEDICATION ERROR MOST COMMON TYPEMOST COMMON ERRORTOTAL NO. OF ERROR QUARTERNo Diagnosis148Prohibited Abbr80No Gen Name168Prescription Previlage57No.file No.98Weak Strength57

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 Nightsrecreational Pregabalin Abuse In An Urban Emergency DeptAuthor AffiliationsEmergency 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 takingincluding name, dosage, frequency, and route.Requires comparing the patients list of current medications against the physicians admission, transfer, and/or discharge ordersNeeds even for OPD patients by MOHhttp://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 PatientFactors:health status of patientsmagnitude of overdosedamage as result of omissionFinancial Implicationsprolong hospital stays & increase health care expenses estimated to cost billions of dollars annuallyadditional medical management

Sources of ErrorPrescribing error - selecting the wrong or inappropriate drug/dose/formulation/duration etcCommunicating those instructionsSupply error - timely; wrong drug, dose, route; expired medicines, labelling.Administration error - timing; wrong route; wrong rate/technique.Lack of user education - actions to take.

WRITE CLEARLY

Mistake identity

Dangerous AbbreviationsAZT for zidovudine (Retrovir)could be azathioprine (Imuran)U HAS been mistaken for zero(o)10 U insulin order & patient received 100 insulin unitsQD has been read as QID or ODDO NOT USE ListsThe Joint CommissionInstitute for Safe Medication Practices (ISMP

Decimal Points & ZerosDecimal point errors cause significant consequencesDecimal point errors occur result of miscalculationwhen writing orders or instructionsresult of artifact on faxed orderAlways write leading zero in front of number < 1Never write trailing zeros

Solution: Enhance Technology Interventionse-Prescribing Systems:Reduced medication errors by 85%Net cost savings of $403,000 in ambulatory care settings22,23Bar Code Electronic Medication Administration System (eMAR) Technology:51% reduction in medication errorsAnnual 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., Barrn, 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 PracticesInterventionResultsPhysician computer order entry 81% reduction of medication errorsPharmacist 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 deliveriesReconciling medication practices upon hospital discharge 90% reduction in medication errors

44Leape, L. L. and Berwick, D. M. (2005). Five years after To Err Is Human: What have we learned? Retrieved 8/1/10 from http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2005/May/Five-Years-After--To-Err-Is-Human---What-Have-We-Learned.aspx

Drug ConcentrationFailure 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 sizesOrder 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 HandwritingHandwriting of physicians is subject of jokesno laughing matter Unclear orders should be clarified Use standardized, preprinted order forms Computer generated & typewritten labelsUse of upper- and lowercase lettering (TALLman)

Missing InformationLack of medical information about patient may cause errorage weight allergies diagnosisindication & severity of condition

Human Error(Mistakes, Slips, Lapses)Error is inevitable due to our limitations:limited memory capacitylimited mental processing capacitynegative effects of fatigue other stressorsWe all make errors all the timePatients suffer adverse events much more often than previously realisedErrors often NOT immediately observed

Safe Medication Practice Unit48So these people your predecessors PERCEIVED that they wouldnt have any problems. Doctors dont go out there, thinking that they will make mistakes.

These are some of the reasons why(points on slide - just need to raise awareness!)

ConclusionsHuman beings will always make errorsErrors are common in medicine, killing tens of thousandsNaming, blaming and shaming have no remedial value

THANK YOU