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MEDICATION ERRORS

UNIVERSITY

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For community transformation

20162016

PRESENTERS

2

1. OPIYO OSCAR

2. LOUM PAUL

3. OYELLA LAURA BRENDA

4. KAKOOLWA BRIAN

3

INTRODUCTION

Medication: A medication: is a substance that is taken into or placed

on the body that does oneof the following things: Most medications are

used to cure a disease or condition. For example, antibiotics are given to

cure an infection. Medications are also given to treat a medical condition.

Error: An error is ‘something incorrectly done through ignorance or

inadvertence; a mistake,e.g. in calculation, judgment, speech, writing,

action, etc.’ or ‘a failure to complete a plannedaction as intended, or the

use of an incorrect plan of action to achieve a given aim’.

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INTRODUCTION CONT…

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Medication error:

In 1995, the United States Pharmacopeial Convention (USP)

spearheaded the formation of National Coordinating Council for

Medication Error Reporting and Prevention (NCCMERP) that defined

medication error as " any preventable event that may cause or lead to

inappropriate medication use or patient harm while the medication is

in the control of the healthcare professional, patient, or consumer.

Such events may be related to professional practice, healthcare

products, procedures, and systems, including prescribing; order

communication; product labeling, packaging, and nomenclature;

compounding; dispensing; distribution; administration; education;

monitoring; and use.”

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Research on why humans make errors (Reason, 1990) has identified two

classes of errors: active and latent.

Active errors (human errors) are those that involve individuals who

are actually doing a task, and their effects are felt almost

immediately.

Latent errors are errors in system or process design, faulty

installation or maintenance of equipment, or ineffective

organizational structure. E.g. an undetected design flaw in an airplane

(a latent error) may, years after the aircraft was built, cause the pilot

to lose control of the plane (an active error) and result in a crash.

(A) CLASSIFICATION OF MEDICAL ERRORS

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(B) CLASSIFICATION OF MEDICAL ERRORS CONT…

NCC MERP has organized medication errors into four major groupings encompassing a total of nine categories (categories A through I):

(a) No Error

- Category A: Circumstances or events that have the capacity to cause error

(b) Error, No Harm

- Category B: An error occurred but the error did not reach the patient (An "error of omission" does reach the patient)

- Category C: An error occurred that reached the patient but did not cause patient harm

- Category D: An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm

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(B) CLASSIFICATION OF MEDICAL ERRORS CONT…

(c) Error, Harm

- Category E: An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention

- Category F: An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization

- Category G: An error occurred that may have contributed to or resulted in permanent patient harm

- Category H: An error occurred that required intervention necessary to sustain life

(d) Error, Death

- Category I: An error occurred that may have contributed to or resulted in the patient’s death

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TYPES OF MEDICATION ERRORS

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There are basically four main types of medication error:

A. PRESCRIBING ERRORS

B. DISPENSING ERRORS

C. DRUG ADMINISTRATION ERRORS

D. MONITORING ERRORS & COMPLIANCE ERRORS

A. PRESCRIPTION ERRORS :

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- Most common type of medication errors.

- Account for 80% of all medication mistakes.

CONTRIBUTING FACTORS FOR PRESCRIPTION ERRORS:

- Inadequate knowledge

- Calculation errors & different drug formulations available

- Uncommon dosage regimen frequencies

- Complicated dosage regimens

- Poor patient history taking Use of multiple dosage forms per dose

- Use of abbreviations Mental slips Lack of adequate resources

- Interruptions while involved in writing prescriptions or orders

- Illegible handwriting & Use of verbal orders.

- Drug name confusion (Look alike Sound alike)

- Inappropriate use of decimal points

A. PRESCRIPTION ERRORS CONT…

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METHODS TO MINIMISE PRESCRIPTION ERRORS:

- Ensuring up-to-date reference sources (e.g. BNFs)

- Use of computerized physician order entry.

- Ensuring knowledge of a drug before prescribing.

- Ensuring an accurate drug history is taken.

- Printing the drug name and patient details clearly on the prescription

- Including all details of drug therapy i.e. name of drug, dose, directions, duration of therapy

- Avoiding the use of abbreviations e.g. PCM, S.P, A/L.

- Being aware of Look alike and sound alike products.

B. DISPENSING ERRORS

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- This error occur at any stage during the dispensing process (from the receipt of a prescription to the supply of a dispensed product to the patient).

- Research estimates that 5% of all prescriptions are dispensed improperly.

- Confusion occurs primarily with drugs that have a similar name or appearance. Lasix® (frusemide) and Losec® (omeprazole) Confusion also occurs between amiloride 5mg and amlodipine 5mg tablets.

CONTRIBUTING FACTORS FOR DISPENSING ERRORS:

- Confusing the name of one drug with another.

- Two or more drugs have a similar appearance or similar name (look-a-like/sound-a-like) Selection of the wrong strength/product.

- Lack of knowledge on new medicines. Use of outdated and/or incorrect references.

B. DISPENSING ERRORS CONT…

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CONTRIBUTING FACTORS FOR DISPENSING ERRORS CONT…

- Poor dispensing procedures with inadequate checking. Unreasonable workloads. Poor housekeeping standards.

- Distractions and interruptions.

- Dispensing unfamiliar products.

- Dispensing before seeing a written order.

- The use of computerised labelling Transposition and typing errors (most common causes of dispensing error).

B. DISPENSING ERRORS CONT…

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METHODS TO MINIMISE DISPENSING ERRORS:

- Methods to Minimise Dispensing Errors - Ensuring a safe dispensing procedure. - Using different brands or separating Look alike and

Sound alike products. - Focusing on the task in hand. - Keeping interruptions to a minimum. - Maintaining workload at a safe and manageable level- Being aware of high risk drugs (HAM) e.g. Hypertonic

Electrolytes (Potassium chloride, Calcium chloride, Magnesium Sulphate), cytotoxic agents, IV Insulin.

- Introducing good housekeeping practices.

C. MED. ADMINISTRATION ERRORS:

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- Discrepancy between the drug therapy received by the patient and the drug therapy intended by the prescriber.

- Administration errors account for 26% to 32% of total medication errors.

EXAMPLES OF MEDICATION ADMINISTRATION ERRORS

(1) Extra Dose Error (2) Wrong dose error (3) Wrong route error(4) Wrong rate error (5) Wrong dosage form(6) Wrong time error (7) Wrong administration technique(8) Administration of expired drugs (9) Administration of wrong preparation(10) Omission Error (e.g: lack of stock).

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CONTRIBUTING FACTORS OF ADMINISTRATION ERRORS:

- Failure to check the patients identity prior to administration.

- Storage of look-a-like preparations side by side in the drug trolley.

- Environmental factors such as noise, interruptions and poor lighting while undertaking the drug round.

- Calculation to determine the correct dose where more than one dose is required.

C. MED. ADMINISTRATION ERRORS CONT…

C. MED. ADMINISTRATION ERRORS CONT…

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METHODS TO MINIZE MED. ADMININSTRATION ERRORS:

- Checking patients identity.

- Having dosage calculations checked independently by another healthcare professional before the drug is administered.

- Having the prescription, the drug and the patient in the same place so they can be checked against one another.

- Ensuring that medication is given at the correct time.

- Minimizing interruptions during drug rounds.

D. MONITORING & COMPLIANCE ERRORS:

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(i) Monitoring Errors: Are errors caused by…

- Failure to review a prescribed regimen for appropriateness/

- Failure to use appropriate clinical or laboratory data to assess the patients’ response to prescribed therapy.

(ii) Compliance Errors: Are errors caused by…

- Inappropriate patient behavior regarding adherence to a prescribed medication regimen

CAUSES OF MEDICATION ERRORS

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1. Missing patient information (allergies, age, weight, pregnancy, etc.)

2. Missing drug information is (outdated references, etc.)

3. Miscommunication of drug order (illegible, incomplete, etc.)

4. Drug name, label, packaging problem (L.A/S.A, faulty drug identity)

5. Drug storage or delivery problem

6. Lack of staff education

7. Drug delivery or device problem (poor device design, IV admn. of oral syringe contents, etc.)

8. Environmental, staffing, workflow (lighting, noise, workload,interruptions, etc.)

CAUSES OF MEDICATION ERRORS CONT…

9. Poor communication with health care teams

10. Poor handwriting

11. Improper drug selection

12. Polypharmacy

13. Drug interactions

14. Lack of computer decision support

15. Lack of Patient education (e.g. patient consultation/non-compliance)

16. Lack of Physician knowledge (when a drug comes to market that replaces an existing one or several ones, i.e., a combination drug may mean that a person takes it once a week instead of daily).

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OTHER CAUSES OF MEDICATION ERRORS

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- Research according to Institute for Safe Medication Practices (ISMP) has illustrated that there are five errors for every 100 orders which reports that…

- 30% of errors are due to deficient drug knowledge, - 20% are caused by limited patient knowledge, - 50 % are a result of poor labeling or drug nomenclature

- Stress/ Fatigue/ Ignorance Personal neglect/ Hesitation Heavy workload Inexperience/Unfamiliarity with medication

- New staff/ Insufficient training - Complicated order - Unfamiliarity with patient’s condition - Faulty judgment - Faulty communication - Failure to monitor closely System flaws

STRATEGIES TO PREVENT MED. ERRORS

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It is important for all nurses to become familiar with various strategies

to prevent or reduce the likelihood of medication errors. Here are ten

strategies to help you do just that.

1. Ensure the five rights of medication administration.

Nurses must ensure that institutional policies related to medication

transcription are followed. It isn’t adequate to transcribe the medication

as prescribed, but to ensure the correct medication is prescribed for the

correct patient, in the correct dosage, via the correct route, and timed

correctly (also known as the five rights).

STRATEGIES TO PREVENT MED. ERRORS CONT…

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2. Follow proper medication reconciliation procedures.

Institutions must have mechanisms in place for medication

reconciliation when transferring a patient from one institution to the

next or from one unit to the next in the same institution. Review and

verify each medication for the correct patient, correct medication,

correct dosage, correct route, and correct time against the transfer

orders, or medications listed on the transfer documents. Nurses must

compare this to the medication administration record (MAR).

STRATEGIES TO PREVENT MED. ERRORS CONT….

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3. Double check—or even triple check—procedures.

This is a process whereby another medical staff on the same shift or an incoming shift reviews all new orders to ensure each patient’s order is noted and transcribed correctly on the physician’s order and the medication administration record (MAR) or the treatment administration record.

4. Have the prescriber (or another medical staff) read it

back.

This is a process whereby a medical staff reads back an order to the prescribing physician to ensure the ordered medication is transcribed correctly.

STRATEGIES TO PREVENT MED. ERRORS CONT….

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5. Consider using a name alert.

Some institutions use name alerts to prevent similar sounding patient names from potential medication mix up. Names such as Johnson and Johnston can lead to easy confusion on the part of nursing staff.

6. Place a zero in front of the decimal point.

A dosage of 0.25mg can easily be construed as 25mg without the zero in front of the decimal point, and this can result in an adverse outcome for a patient.

7. Records and Documentation.

This includes proper medication labeling, legible documentation, or proper recording of administered medication.

STRATEGIES TO PREVENT MED. ERRORS CONT….

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8. Ensure proper storage of medications for proper efficacy.

Medications that should be refrigerated must be kept refrigerated to maintain efficacy, and similarly, medications that should be kept at room temperature should be stored accordingly. Most biologicals require refrigeration, and if a multidose vial is used, it must be labeled to ensure it is not used beyond its expiration date from the date it was opened.

9. Learn your institution’s medication administration policies, regulations, and guidelines.

This is where education comes into play whereby the institution’s educator or education department (CME) educates medical personnel on the content of their medication policy. These policies often contain vital information regarding the institution’s practices on medication ordering, transcription, administration, and documentation.

STRATEGIES TO PREVENT MED. ERRORS CONT….

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10. Consider having a drug guide available at all times.

Whether it’s print or electronic is a matter of personal (or institutional) preference, but both are equally valuable in providing important information on most categories of medication, including: trade and generic names, therapeutic class, drug-to-drug interactions, dosing, nursing considerations, side effects/adverse reactions, and drug cautionaries such as “do not crush, or give with meals.”

ADMINISTRATORS SHOULD DO THE FOLLOWING:

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1. A safety culture is pivotal to improving medication safety

(encourage voluntary reporting)

2. Devote adequate attention to safety

3. Provide sufficient resources to quality improvement and

safety teams

4. Authorize resources to invest in technologies, such as

computerized provider order entry (CPOE) and electronic

health records

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PREPARING AND DISPENSING

PLANNING

EVALUATINGSELECTION AND PROCUREMENT

PRESCRIBINGADMINISTERING

STORAGEMONITORING

THE MEDICATION MANAGEMENT PROCESS

MEDICATION

MANAGEME

NT CYCLE

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THE END

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