medication errors 2011

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Medication Errors

Course Name: Hospital PharmacyCourse code: PHC222Date: December 2011 (DK1)


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At the end of this lecture you will be able to:define the term medication errors

identify medication error severity levelsflow chart of medication errorsdescribe different types of medication errorsidentify causes, risk factors that contribute tomedication errorssuggest ways to prevent medication errors


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ME is any preventable event that may cause orlead to inappropriate medication use or patientharm while the medication is in the control of thehealthcare professional, patient or consumer.

Any error occurring in the medication-useprocess.

Writing a medication order, Interpreting &transcribing medication orders, preparing &dispensing medications or administration of medicines.


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The main goal of drug therapy is to achieve a definedtherapeutic outcomes that improves a pt s QOL.

However, there are inherent risks (known & unknown),

associated with therapeutic use of drug administration.Problems & sources of ME are multidisciplinary &multifactorial.

May be committed by both experience & inexperiencestaff.

Many ME are probably undetected.


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Doses omittedWrong doseUnprescribed drug givenWrong dosage formgivenWrong route of administrationWrong rate of administration

YesYes

YesYes

Yes

Yes


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Wrong time of administration

time of dayin relation to food etc....

Using unstable/expireddrugWrong administration

techniqueIncorrect reconstitutionExtra dose given

Yes

Yes

Yes

Yes


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Prescriber writes the Rx

Pharmacy receives, screen & interpret the Rx fromward

Drugs put into medication drawer/bin of individual ptby pharmacy assistant

Counterchecking med filled before

deliveryTrolley with med bins sendto ward

Patient in ward

Nurse administers

drug to pt

Trolley returnback to satellite


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Point for prescribing error

Point for dispensing error

Point for error by nurses

Point for error by patient


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occurs at the time a prescriber orders a drug for a specificpatientsErrors may include, incorrect drug selection (based onindications, C/I, known allergies, existing therapy), dose,dosage form, quantity, route, concentration, rate of administration, or instruction for use.

Rx that are filled incorrectly due to illegible handwritingwould be considered prescribing error.

E.g.: Rx for amoxicillin 250mgPO TID may be appropriate totreat a middle ear infection in a 5-year-old child but wouldbe too high a dose for a 12-month-old infant.

Prescribing errors


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Administration of medication to a pt without properauthorization by the prescriber.

It might occur if a med for one pt was mistakenly given toanother pt, or if a nurse gave a med without physician order.

Refilling a prescription that has not refills remainingwithout authorization from the physician is anotherexample of unauthorized drug errors.

Administration of medications outside the establishedguidelines is another example of unauthorized drug errors.

Unauthorized drug errors


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Administration to pt of a dose that is moreor less than the prescribed dose .

This type of error may occur if there is adelay or absence in documenting anadministered dose that results in an

additional dose being administered.Inaccurate measurement of an oral liquid isalso an improper dose error.

Improper dose error


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Doses administered or dispensed in adifferent form from that ordered by theprescriber.

In certain cases changes in dosage form areacceptable according to the pts need and

thus not considered as wrong dosage formerrors. For e.g. dispensing a liquidpreparation without a specific prescriptionto a pt who has difficulty swallowing tablets.

Wrong dosage form error


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Drug product incorrectly formulated ormanipulated before administration.

Incorrect dilution or reconstitution, mixingincompatible & inadequate product packaging.

For e.g. using bacteriostatic saline for injectioninstead of sterile water for injection to reconstitutea lyophilized powder for injection

Wrong drug-preparation error


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Doses that are administered using aninappropriate procedure or incorrecttechnique.

For e.g. wrong route & site of administration, wrong rate etc.

Wrong administration-technique error


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Administration of a drug that expired or forwhich the physical or chemical dosage form

integrity has been compromised.Drugs that have passed their expiration datemay have lost their potency and may be lesseffective or ineffective.

Deteriorated drug error


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Monitoring errors result from inadequate drugtherapy review.

Failure to use appropriate clinical or laboratorydata for adequate assessment of pt response toprescribed therapy.

For e.g. failure to respond to the levels of phenytoin above therapeutic range or failure tomonitor blood pressure after administering ablood lowering antihypertensive medication.

Monitoring error


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Inappropriate pt behavior regardingadherence to a prescribed regimen.

These errors may be detected when a ptrequests refills of prescriptions at an

unreasonable intervals (too long or toosoon before a refill is due) without areasonable explanation.

Compliance error


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Ambiguous strength designation on labels or in packaging.Drug product nomenclature look-alike, sound-alike names.(Amrinone(Inocor) Vsamiodarone (Cordarone)

Equipment failure or malfunction.

Illegible handwriting (Aredia (pamidronate) Vs Adria (doxorubicin)Improper transcription

Inaccurate dosage calculation (calculation error, decimal points and zeros)

Inadequately trained personnel

Inappropriate abbreviations used in prescribing (U as an abb of units, QD instead of dailyas it could be read as QID)

Labeling error

Excessive workload

Poor work environment (light, noise, poorely design work place etc)


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Type of distribution system Unit of dose system ispreferred

Improper drug storage

Extent of measurement / calculation required

Confusing drug product nomenclature

Poor handwriting

Verbal orders

Lack of policies & procedures


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Participate in drug therapy monitoring.Rx screening, drug use evaluation (DUE) activities.

Stay abreast of current state of knowledge &participate in CE programs & provision of drug info.

Offer prescriber & nurses info & advice abouttherapeutic drug regimens.

Never assume or guess the intent of confusing ME.

Maintain orderliness & cleanliness in work area.


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For high risk product, all work should be double-checked by a 2 nd pharmacist to make certain thatthe drug labeling, packaging, quantity, dose &instructions are accurate.

Review the use of auxiliary labels.

Ensure meds are delivered to pt care area in a timelyfashion after receipt of med orders.

Review med orders-drug name & dosage regimen.

Review med that are returned to pharmacy-omitteddoses or unauthorized drugs.


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Verify of pt s understanding about Rxinstruction & labeling.

Pt counseling service should be offered tohigh risk pt for ME & adverse drug events.

Maintain sufficient records to enableidentification of pts receiving an erroneousproducts.


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medication errors 2011

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