Safety Medication errors Chapter Topics Medical errors Medication errors Prescription filling process in community and hospital pharmacy practices Medication error prevention Medication error reporting systems Learning Objectives Understand the extent of medical and medication errors and their effects on patient health and safety. Identify specific categories of medication errors. Discuss examples of medication errors commonly seen in pharmacy practice settings. Apply a systematic evaluation to search for medication error potential to a pharmacy practice model. Define strategies, including the use of automation, for preventing medication errors. Identify the common systems available for reporting medication errors. Medical Errors Definition Any circumstance, action, inaction or decision related to health care that contributes to an unintended health result Examples Lab test drawn at the wrong time that returns an inaccurate result Infection resulting from improper technique Major surgical error that results in death Medical Errors (continued) Scope and impact 98,000 deaths in the United States per year due to medical errors in hospitals Medical errors are the sixth leading cause of death in the United States. Government and private insurers no longer reimburse hospitals for additional costs associated with medial errors. Hospitals cannot bill patient for costs associated with medical errors Medication Errors Definition 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 Includes prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use Medication Errors (continued) Scope and impact Drug errors in U.S. hospitals cause 400,000 preventable injuries per year. In the United States, 7,000 deaths occur each year due to medication errors in hospitals. About 1.7% of prescriptions dispensed in a community practice setting contain a medication error. About $3.5 billion per year is spent on direct and indirect costs of medication errors. Additional hospitalizations Long-term care Physician visits Emergency room visits Medication Errors (continued) Patient response Physiological causes of medication errors Increased susceptibility to medications Absence of enzyme that removes medication from the body Poor kidney function Young patients (under 6 years old) Elderly patients (over 66 years old) Social causes of medication errors Failure to follow directions Misunderstanding directions Noncompliance Medication Errors (continued) Categories of medication errors Classic Examples of Medication Errors ErrorDefinition Omission errorA prescribed dose is due, but not administered. Wrong dose errorA dose is either above or below the correct amount by more than 5%. Extra dose errorA patient receives more doses than were prescribed. Wrong dosage form error The dose formulation given is not the accepted interpretation of the physicians order. Wrong time errorAny drug given 30 minutes or more before or after directed is considered a wrong time error. Medication Errors (continued) Categories of medication errors Classes of Failure for Medication Errors ErrorCauseExample Human failureOccurs at an individual level Pulling a medication bottle from the shelf based on memory without checking labels Technical failure Results from equipment problems Incorrect reconstitution of a medication because of a malfunction of a sterile- water dispenser Organizational failure Results from a deficiency in organizational rules, policies, or procedures Policy requiring the preparing of chemotherapy in an inappropriate setting Medication Errors (continued) Root-cause analysis of medication errors A logical and systematic process used to help identify what, how, and why something happened to prevent recurrence Error occursPotential causes identifiedAction taken to avoid more errorsImprovement in quality of workBoost in outcomes Medication Errors (continued) Root-cause analysis of medication errors Root-cause Analysis of Medication Errors ErrorCauseExample Assumption error An essential piece of information cannot be verified and an assumption is made. A prescription contains an illegible abbreviation, drug name, or directions and is misread. Selection errorTwo or more options exist and the wrong one is chosen. A look-alike or sound-alike drug is filled instead of the prescribed drug. Capture errorFocus on a task is diverted elsewhere. The wrong number of tablets are dispensed while taking a phone call in the middle of filling a prescription. Prescription-Filling Process Prescription-Filling Process (continued) Each step in the filling process broken into parts Information that needs to be obtained or checked Resources that can be used to verify information Potential medication errors that would result from a failure to obtain or check the necessary information Each person who participates in the filling process has the opportunity to catch and correct a medication error. Prescription-Filling Process (continued) Step 1: Receive and review prescription Basic review of prescription Verbal order precautions Clarify the order before moving to next step. Ask the caller to read back the order. Validity of prescription Determine whether the prescription is legal and valid. Look at the date and signature. Outdated prescriptions should not be filled. Prescription-Filling Process (continued) Step 1: Receive and review prescription Detailed review of prescription Prescriber information Determine whether a licensed and qualified prescriber wrote the prescription. Look for the signature and contact information. Patient information Check enough details to pinpoint a unique individual. Full names, addresses, dates of birth, and phone numbers are standard identifiers. Date of birth and allergies help determine appropriateness of medication. A prescribers signature is required for a written prescription to be considered valid. Prescription-Filling Process (continued) Step 1: Receive and review prescription Detailed review of prescription Medication information Drug name, strength, dose, dosage form, route of administration, refills or length of therapy, directions, and dosing schedule Prescribing errors Poor handwriting, nonstandard abbreviations, sound-alike and look- alike drug names, and as directed Incorrect notation of numbers Abbreviations qd, qid, and qod A leading zero should precede values less than one, but no zero should follow a decimal if the value is a whole number. In the Know: True or False Medication errors are the 25 th leading cause of death in the United States. false Costs associated with medication errors include emergency room visits. true A wrong dosage form error occurs when the incorrect strength of a medication is dispensed. false A prescribers signature is required in order for a written prescription to be considered valid. true Prescription-Filling Process (continued) Step 2: Enter prescription into the computer Accurate data entry As each piece of information is entered, compare the choices from the computer menu with the prescription. Drug names, dosages, formulations, concentrations, and increments of measure Prescription-Filling Process (continued) Step 2: Enter prescription into computer Potential dangers Teaspoons vs. milliliters Potential for five-fold error Milliliters recommended for computer entry and labeling to minimize errors Formulation mix-ups Concentration mix-ups Ointments vs. creams Solutions vs. suspensions Precautions with scheduled drugs Immediate release vs. sustained release oxycodone products Prescription-Filling Process (continued) Step 3: Perform drug utilization review and resolve medication issues Drug utilization review (DUR) Dosing ranges and drug interactions Pharmacist should perform a DUR for dosing ranges, drug interactions, or duplication of therapy. Particular care is warranted for pediatric, elderly, and pregnant patients. Allergy-related alerts Computer system flags allergies which should be brought to the attention of the pharmacist. Prescription-Filling Process (continued) Step 3: Perform drug utilization review and resolve medication issues Drug utilization review (DUR) Pharmacist follow-up The pharmacist must decide whether to counsel the patient or contact the prescribing physician prior to approving the prescription. Check the patient profile for existing allergies or possible drug interactions. Prescription-Filling Process (continued) Step 4: Generate prescription label Cross-check the label output from the printer with the original prescription. Patient name Drug Dose Concentration Route Prescription-Filling Process (continued) Step 5: Retrieve medication Safe practices for accurate drug selection NDC numbers Cross-check NDC number Specific to a particular form, package, and strength Specific NDCs for drug forms Even at same strength Prescription-Filling Process (continued) Step 5: Retrieve medication Safety practices for accurate drug selection Heparin safeguards Serious medication errors have occurred when an incorrect heparin concentration was used. Additional computer alerts, nurse-check-nurse systems, and limited availability of certain concentrations on nursing units help avoid Heparin errors. Look-alike and sound-alike labels Computer-based pill identification programs facilitate visual comparison of the medication dispensed. Prescription-Filling Process (continued) Step 6: Compound or fill prescription Safety practices for accurate compounding and filling Equipment maintenance Equipment used should be maintained, cleaned, and calibrated regularly. Check the accuracy of technology. Auxiliary labels Most computerized systems generate them at the same time as the medication label. Patients are reminded of the most crucial aspects of proper medication administration. They should always be included with prescription labeling. Prescription-Filling Process (continued) Step 7: Obtain a pharmacist review and approval Responsibilities of the pharmacist Verify the initial computer entry. Check the quality and integrity of the end product. Compare the label to the stock bottle and the prescription. The stock bottle should accompany the labeled medication container and original prescription. Role of the technician in the verification process To develop an awareness of what is needed by a pharmacist, practice checking a colleagues work. The pharmacist must always check the technicians work. Prescription-Filling Process (continued) Step 8: Store completed prescription Proper storage conditions Some drugs are sensitive to light, humidity, or temperature. Improper storage may result in loss of drug potency or effect. Refrigerator and freezer temperatures must be monitored and documented. Orderly storage decreases the chances of one patients medications getting mixed up with anothers. Prescription-Filling Process (continued) Step 9: Deliver medication to patient Verification of patient identity Confirm the patients date of birth or address rather than just his or her name. Explanation of medication to patient Double-check the number of medications the patient expects to receive. Inquire as to the patients knowledge of their proper use. Consult the pharmacist if the patient has questions. Prescription-Filling Process (continued) Step 9: Deliver medication to patient Show and Tell technique with patient Open the vial and show the drug product to the patient. Take the opportunity to double check that the correct drug was put into the vial. Have the patient point out if refilled drug looks different from a previously filled drug. Prescription-Filling Process (continued) Step 9: Deliver medication to patient Show and Tell technique with patient ISMPs Tell-Back system Uses patient-centered, open-ended questions to help determine patient understanding Pharmacy technicians cannot instruct patients about their medications. If a technician suspects that a patient requires instruction, then the technician should alert the pharmacist. In the Know: True or False When the computer provides an allergy alert, the technician should bypass the alert and fill the prescription. false The NDC number is an excellent mechanism for checking if the correct product is selected. true The medication dose is provided on the auxiliary labels. false When delivering a medication to a patient, verifying his or her first and last names is sufficient. false Medication Error Prevention Role of the pharmacy technician Opportunities to identify errors throughout process Interacting with nurse or patient Receiving and examining the prescription Entering data into the computer Submitting prescription for filling Giving the medication to the patient Incorrect drug identification is the most common error in dispensing or administration. Medication Error Prevention (continued) The responsibility of healthcare professionals A commitment to first do no harm Put safety first. Pharmacy exists to safeguard the health of the public. Focus on treating the patient and ensure the best possible outcomes by the safest means. The only acceptable number of medication errors is zero. Medication Error Prevention (continued) The responsibility of healthcare professionals Avoiding potential sources of errors Technicians should listen and observe carefully during patient or medical staff interactions. Technicians who assume more routine dispensing tasks allow the pharmacist more time for counseling and taking more detailed, accurate medical histories. If information is missing from a prescription or medication order, a pharmacy technician must obtain the information from the prescriber. The technician should never make conjectures regarding missing content. Medication Error Prevention (continued) Patient education Pharmacy technicians role Encourage patients to ask questions, provide complete medical and allergy history, and check medication labels. Actively monitor for potential errors or patient misunderstandings. Encourage patients to be informed about their conditions. Encourage patients to ask the pharmacist questions. Add information to patient profiles about prescriptions filled at other pharmacies or mail order. Encourage patients to call the pharmacist if questions arise after leaving the pharmacy. Medication Error Prevention (continued) Patient education Information Patients Must Know about Their Medications 1. Brand and generic names 2. The medications appearance 3. The purpose of the medication, and the duration of treatment 4. The correct dosage and frequency, and the best time or circumstances to take a dose 5. How to proceed if they miss a dose 6. Medications or foods that interact with the prescribed medication 7. Whether the prescription is in addition to or replaces a current medication 8. Common side effects and how to handle them 9. Special precautions necessary for each particular drug therapy 10. Proper storage for the medication Medication Error Prevention (continued) Innovations to promote safety E-prescribing Preprinted prescriptions Drug, dose, schedule, frequency, amount dispensed can be circled Minimizes transcription or illegible prescription errors Common with specialists who prescribe a limited number of drugs Use of automation E-prescribing eliminates the problem of illegible prescriptions or soundalike medications causing a preventable error. Medication Error Prevention (continued) Innovations to promote safety Workplace ergonomics Workplace Ergonomic Practices to Promote Safety 1. Automate and bar code all procedures. 2. Maintain a clean, organized, and well-lit work area. 3. Provide adequate storage areas with clear drug labels on the shelves. 4. Encourage prescribers to employ common terminology and only use safe abbreviations. 5. Provide adequate computer applications and hardware. Medication Error Prevention (continued) Innovations to promote safety Package, medication, and label design Package design Clear labeling, large font size, easy-to-use dispenser, label Targets ClearRx design Designed to help patients manage their medications Information clear, easy-to- read format Medication Error Prevention (continued) Innovations to promote safety Package, medication, and label design Medication design Formulations with unique colors, shapes, or markings Markings on tablet or capsule that verify the dose Different colors for different doses of the same medication Capsule identification on the stock bottle Middle four numbers of the NDC in larger font or boldface type Medication Error Prevention (continued) Innovations to promote safety Package, medication, and label design Label design tall man or enhanced lettering Warning statements on stock labels of high-risk medications Medication Error Prevention (continued) Innovations to promote safety Use of automation Bar-coding technology Prescription entered into computer and verified Stock bottle selected NDC number of stock bottle scanned Computer compares scanned bar code against prescription Error message if no match Medication Error Prevention (continued) Innovations to promote safety Use of automation Bar-coding technology Automated dispensing cabinets are maintained primarily by pharmacy technicians. Robot-based medication dispensing increases efficiency and speed of medication delivery without compromising safety. The robot uses bar codes to validate drugs, significantly reducing the chances of drug selection errors. Medication Error Prevention (continued) Innovations to promote safety Use of integrated, automated system Medication sent to nursing unit Order filled by technician or robot Order double-checked by pharmacist Order sent to the pharmacy Physician inputs order Medication Error Prevention (continued) Innovations to promote safety Use of integrated, automated system Nurse documents medication administration on electronic medication administration record (eMAR) Nurse matches bar code on medication with that on patients wristband Medication arrives on nursing unit Medication Error Prevention (continued) Professional prevention strategies ASHPs Pharmacy Technician Initiative Enhances education and training of pharmacy technicians Improves patient safety Minimizes medication errors ASHP-accredited pharmacy technician training program PTCB Certification State Board Registration Eligibility to work in a hospital pharmacy Medication Error Prevention (continued) Personal prevention strategies Lifestyle recommendations Get enough sleep. Exercise regularly. Take breaks at work. Be wise about food. Avoid excessive alcohol. Cut the caffeine. Even when things are busy, take breaks to relax and revitalize yourself, even if it means going outside to clear your head for a couple of minutes. You will not be much help if you cannot think clearly. In the Know: True or False A pharmacy technician can help detect errors by carefully listening and observing during patient interactions. true One of the recommended pieces of information patients must know about their medications is the cost. false Tall man or enhanced lettering is an example of an innovation to promote patient safety. true A personal prevention strategy in preventing medication errors is to listen to a headset while at work. false Medication Error Reporting Systems State Boards of Pharmacy Overview: Some states have mandatory error-reporting systems. Boards of Pharmacy do not punish pharmacists for errors, as long as a good-faith effort was made to fill the prescription correctly. Some states regulate, require, or recommend a continuous quality improvement (CQI) program to detect, document, and assess medication errors. Some states have proposed new laws that protect error reports from subpoena. Medication Error Reporting Systems (continued) State Boards of Pharmacy Error reporting Telling the PatientTelling the Physician The pharmacist is typically the one to report a medication error. The physician must be contacted if the error will lead to a side effect. Circumstances leading to the error should be explained completely and honestly. The prescriber must be notified if the error will cause an adverse drug reaction. Patients should understand the nature of the error, what effects the error may have, how he or she can actively prevent errors in the future. The physician must be told if the error will impact the disease being treated. Medication Error Reporting Systems (continued) Joint Commissions Sentinel Event Policy Sentinel event is reported. The organization (hospital, pharmacy, or HMO) analyzes the cause of error. The organization takes action to correct the root cause. The organization monitors the changes made. The organization determines whether the cause of the error is eliminated. Medication Error Reporting Systems (continued) Joint Commission Accreditation and medication safety Joint Commission supports the ISMP recommendations Elimination of certain abbreviations Education regarding frequently confused drug names May recommend a safety program to improve communications in the ordering, preparation, and dispensing of medications Standards recommend that hospital outline its responsibility in advising a patient about adverse outcomes of error. Medication Error Reporting Systems (continued) Joint Commissions SPEAK UP Campaign Speak up if you have questions or concerns. S Pay attention to the care you get. P Educate yourself about your illness. E Ask a trusted family member or friend to be your advocate. A Know what medications you take and why you take them. K Use a healthcare organization that has been carefully checked out. U Participate in all decisions about your treatment. P Medication Error Reporting Systems (continued) United States Pharmacopeia MEDMARX reporting system Internet based system Allows healthcare professionals to anonymously document, analyze, and track adverse events Most recent report shows that more than 60% of medication errors occur during dispensing, technicians involved in 38.5% of them. Major contributing factors to medication errors include distraction in the workplace, excessive workload, inexperience. Medication Error Reporting Systems (continued) Institute for Safe Medication Practices (ISMP) Overview: A nonprofit healthcare agency Membership comprised of physicians, pharmacists, and nurses Mission To understand the causes of medication errors To provide and communicate error-reduction strategies to the healthcare community, policymakers, and the public Does not set standards but focuses on expert analysis and scientific studies to reduce medication errors Medication Error Reporting Systems (continued) Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program (ISMP MERP) ISMP provides legal protection and confidentiality for submitted patient safety data and error reports. Allows the healthcare professional to report medication errors directly ISMP shares all information and error-prevention strategies with the FDA. Medication Error Reporting Systems (continued) Other ISMP initiatives Publishes checklist of strategies to prevent medication errors Publishes a list of common look-alike and sound-alike drugs Sponsors national forums on medication errors Recommends additional labeling on potentially toxic drugs Encourages revisions of potentially dangerous prescription writing practices Disseminates information to healthcare professionals and consumers Chapter Summary Pharmacy technicians play a crucial role in the prevention of medication errors. Knowing the potential causes and categories of medication errors is the first step in preventing them from occurring. Medication errors may result from physiological or social causes. Medication errors can be further categorized as omission, wrong dose, extra dose, wrong dosage form, and wrong time of administration. Once errors are identified by root-cause analysis, corrective measures should be put in place, and permanent elimination of the source of error should be the goal. Chapter Summary (continued) Each step of the medication-filling process has the potential to produce a medication error. Specific practices, careful work habits, and a clean work environment promote patient safety and decrease illness and injury caused by medication errors. Although pharmacy technicians cannot counsel patients concerning their medications, they can encourage them to ask questions of the pharmacist. Helping patients become more informed also empowers them to be advocates for their own safety and health. Chapter Summary (continued) Automation and technological advances including e- prescribing and bar-code scanning can minimize medication errors. Medication error prevention must be emphasized by al healthcare team members. The pharmacy technician should adopt effective personal prevention strategies to minimize human errors. Several medication error reporting systems exist. Pharmacy personnel should be familiar with these outlets and use them to confidentially report errors so that the errors do not occur again. The Joint Commission has published an unapproved abbreviations list to minimize medication errors.