medications

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Chapter 6
Medication Safety
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Learning Objectives

• Understand the extent and effect of medical
  errors on patient health and safety
• Describe how and to what degree medication errors
  contribute to medical errors
• List examples of medication errors commonly seen
  in practice settings
• Apply a systematic evaluation of opportunities
  for medication error to a pharmacy practice model
• Identify the common medication errorreporting
  systems available

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Medical Errors

• A medical error is any circumstance, action,
  inaction, or decision related to healthcare that
  contributes to an unintended health result
• Most of what is known about medical errors comes
  from information collected in the hospital
  setting
• hospital data make up only a part of a much
  larger picture
• most healthcare is administered in the
  outpatient, office-based, or clinic setting
• Medical errors are difficult to define
• possible causative circumstances are infinite

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Medical Errors

• Medical-related lawsuits show the scope of
  medical errors in the United States
• One large government studied only medical errors
  during hospitalization
• 44,000 to 98,000 people in the U.S. die each year
  as a result of medical errors (greater than the
  risk of death from accident, diabetes, homicide,
  or human HIV and AIDS)
• multiple sources for potential medical errors
  exist

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Discussion
What are some examples of medical errors?
Edited by Dr. Ryan Lambert-Bellacov
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Discussion
What are some examples of medical
errors? Answer Lab tests drawn at the wrong
time (inaccurate results), major surgical errors
ending in injury or death
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Medication Errors

• A medication error is a medical error in which
  the source of error or harm includes a medication
• Like medical errors
• medication errors have no specific definition
  because the possible causes can be endless
• information on the effect of medication errors
  comes mostly from studies done in the hospital
  setting
• Medication-related deaths are estimated at about
  7,000 each year

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Medication Errors

• Fewer studies of medication errors in community
  practice exist
• an estimated 1.7 of all prescriptions dispensed
  in a community practice setting contain a
  medication error (4 of every 250
  prescriptions)
• Not all medication errors result in harm to a
  patient
• 65 of the medication errors detected had a
  meaningful effect on the patients health

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Medication Errors

• Measuring results of medication errors
• lost lives
• disabled patients
• time lost from work or school
• cost to the healthcare system

billions of dollars physician visits
additional hospitalizations emergency room visits
admissions to long-term care continuation of disease
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Healthcare Professionals Responsibility

• Working in healthcare means making a commitment
  to first do no harm
• The profession of pharmacy exists to safeguard
  the health of the public
• Healthcare must focus on treating the patient
• to the best possible outcome
• by the safest possible means
• No acceptable level of medication error exists
• effect of a potential medication error on the
  patient cannot be predicted
• each step in fulfilling medication orders should
  be reviewed with a 100 error-free goal

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Healthcare Professionals Responsibility
Safety Note
The only acceptable level of medication errors
is zero.
Edited by Dr. Ryan Lambert-Bellacov
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Healthcare Professionals Responsibility

• MAs can identify potential patient sources of
  medication error
• careful listening and observation during a
  patient or medical staff interaction
• notifying the pharmacist
• MAs make a significant contribution to patient
  safety
• constant surveillance for potential sources of
  medication error

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Tips for Reducing Medication Errors

• Always keep the prescription and the label
  together
• Know common look-alike and sound-alike drugs
• Keep dangerous or high-alert medications in a
  separate storage area
• Always question bad handwriting
• Prescriptions/orders should be correctly spelled
  with drug name, strength, appropriate dosing,
  quantity or duration of therapy, dose form, and
  route
• Use the metric system

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Tips for Reducing Medication Errors

• Question uncommon abbreviations
• Be aware of insulin mistakes
• Keep the work area clean and uncluttered
• Verify information
• Labels should always be compared with the
  original prescription by at least two people

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Healthcare Professionals Responsibility
Safety Note
If information is missing from a medication
order, never assume. Obtain the missing
information from the prescriber.
Edited by Dr. Ryan Lambert-Bellacov
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Tips for Reducing Medication Errors MAs

• Use the triple-check system
• Regularly review work habits
• Verify information with the patient or caregiver
• Observe and listen
• Keep your work area free of clutter

Edited by Dr. Ryan Lambert-Bellacov
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Patient Response

• Most patients have the intended therapeutic
  response expected from the medication
• Unique physical and social circumstances make it
  impossible to predict which
• medication errors may result in no substantial
  harm
• may result in death

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Physiological Causes of Medication Errors

• Each patient has a unique response to medication
• genetically unique
• speed at which medications are removed from
  body varies
• Even a problem caught and corrected before harm
  occurs is still considered a medication error

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Social Causes of Medication Errors

• Outpatients can contribute to medication errors
  through incorrect administration
• Social causes of error include
• failure to follow medication therapy instructions
  because of cost
• noncompliance
• failure to receive therapy
• misunderstanding instructions (language barriers)

Edited by Dr. Ryan Lambert-Bellacov
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Social Causes of Medication Errors

• Patients can contribute to medication errors by
• forgetting to take a dose or doses
• taking too many doses
• dosing at the wrong time
• not getting a prescription filled or refilled in
  a timely manner
• not following directions on dose administration
• terminating the drug regimen too soon

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Social Causes of Medication Errors

• Social causes may result in an adverse drug
  reaction, or a toxic dose
• Over 50 of patients on necessary long-term
  medication are no longer taking their medication
  after 1 year
• All of these social circumstances would be
  considered medication errors

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Categories of Medication Errors

• Possible causes of a medication error are
  numerous
• Categorizing errors into types aids in
  identification and prevention of possible causes
• Categories focus on grouping errors under a set
  of common definitions

Edited by Dr. Ryan Lambert-Bellacov
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Categories of Medication Errors

• omission error a prescribed dose is not given
• wrong dose error a dose is either above or below
  the correct dose by more than 5
• extra dose error a patient receives more doses
  than were prescribed by the physician
• wrong dose form error dose form or formulation
  that is not the accepted interpretation of the
  physician order
• wrong time error drug is given 30 minutes or
  more before or after it was prescribed

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Categories of Medication Errors

• Errors can be classified by what causes the
  failure of the desired result
• Errors can be categorized within three basic
  definitions of failure
• human failure
• technical failure
• organizational failure

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Categories of Medication Errors

• Human failure is a failure that occurs at an
  individual level
• pulling a medication bottle from the shelf based
  on memory, without cross-referencing the bottle
  label with the medication order/prescription
• errors made by the patient such as non-compliance
  to prescribed drug therapy
• Technical failure is a failure resulting from
  location or equipment
• incorrect reconstitution of a medication because
  of a malfunction of a sterile-water dispenser
• failure to properly operate automated equipment

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Root Cause Analysis of Medication Errors

• Root cause analysis is a logical and systematic
  process used to help identify what, how, and why
  something happened to prevent reoccurrence
• With basic principles of root cause analysis, any
  person can
• examine his or her own work flow to determine the
  opportunities for potential error
• determine what type of failure the potential
  error may be
• create a list of specific potential causes

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Root Cause Analysis of Medication Errors

• Identifying specific potential causes allows a
  person to take specific actions to prevent the
  potential error
• Actions taken improve the quality of work being
  done
• Common causes of medication error by handlers and
  preparers include
• assumption error
• selection error
• capture error

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Root Cause Analysis of Medication Errors

• assumption error an essential piece of
  information cannot be verified and is guessed or
  presumed
• misreading an abbreviation on a prescription
• selection error two or more options exist, and
  the wrong option is chosen
• using a look-alike or sound-alike drug instead of
  prescribed drug
• capture error focus on a task is diverted
  elsewhere and an error goes undetected
• something captures the persons attention,
  preventing the person from detecting the error or
  causing an error to be made

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Root Cause Analysis of Medication Errors
Safety Note

• Maintaining focused attention when filling
  prescriptions is important to avoid errors.

Edited by Dr. Ryan Lambert-Bellacov
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Prescription-Filling Process in Community and
Hospital Pharmacy Practice

• Review for potential causes of medication error
  begins with outlining work tasks in a
  step-by-step manner
• Each step in this process can be a
• source of medication error
• place where pharmacy personnel can correct a
  medication error

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Prescription-Filling Process in Community and
Hospital Pharmacy Practice
Safety Note
Each person who participates in the filling
process has the opportunity to catch and correct
a medication error.
Edited by Dr. Ryan Lambert-Bellacov
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Prescription-Filling Process
Safety Note
Outdated prescriptions should not be filled.
Edited by Dr. Ryan Lambert-Bellacov
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Prescription-Filling Process
Safety Note
A prescribers signature is required for a
prescription to be considered valid.
Edited by Dr. Ryan Lambert-Bellacov
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Prescription-Filling ProcessStep 1

• Prescribing errors include
• poor handwriting
• using nonstandard abbreviations
• confusing look-alike and sound-alike drug names
• wrong drug
• using as directed instructions

Edited by Dr. Ryan Lambert-Bellacov
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Prescription-Filling ProcessStep 1
Edited by Dr. Ryan Lambert-Bellacov
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Prescription-Filling Process
Safety Note
A leading zero should precede values less than
one, but a zero should not follow a decimal if
the value is a whole number. A tenfold error
occurs if the decimal point is not detected.
Edited by Dr. Ryan Lambert-Bellacov
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Prescription-Filling ProcessStep 1

• Opportunities for medication errors increase with
  the number of medications a patient takes
• common with many older patients
• Profile review for every prescription should
  include
• check for existing allergies and multiple drug
  therapy
• check for drug interactions or duplication of
  therapy

Edited by Dr. Ryan Lambert-Bellacov
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Prescription-Filling Process
Safety Note
Check the patient profile for existing allergies
or possible drug interactions.
Edited by Dr. Ryan Lambert-Bellacov
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Prescription-Filling Process

• Retrieve Medication
• Products can contribute to errors with
• look-alike labels
• similarities in brand or generic names
• similar pill shapes or colors
• Use NDC numbers, drug names, and other
  information to verify selection of the correct
  product
• use both the original prescription and the
  generated label when selecting a manufacturers
  drug product from the storage shelf
• use NDC numbers as a cross-check

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Prescription-Filling Process

• Step 5 Fill or Compound Prescription
• Calculation and substitution errors are sources
  of medication errors
• write out the calculation and have a second
  person check the answer
• Take care when reading labels and preparing
  compounded products

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Medication Error Prevention

• Preventing medication errors means
• carefully examining potential points of failure
• using available resources to verify information
  given or decisions made
• Drug identification is the most common error in
  dispensing and administration

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Medication Error Prevention
Safety Note
Incorrect drug identification is the most common
error in dispensing or administration.
Edited by Dr. Ryan Lambert-Bellacov
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Medication Error Prevention

• Many medication errors occur during prescribing
  and administration
• Prescribers are responsible for ensuring the
  five Rs or five rights
• the right drug
• for the right patient
• at the right strength
• given by the right route
• administered at the right time

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Innovations to Promote Safety

• The physical pharmacy work setting can have a
  major contribution to the overall safety of any
  work environment
• Automate and bar code all fill procedures
• Maintain a clean, organized, orderly work area
• Provide adequate storage areas
• Encourage prescribers to use common terminology
  and only safe abbreviations
• Provide adequate computer applications and
  hardware

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Innovations to Promote Safety

• Innovations can minimize possibility of errors
• In community pharmacy, redesigned packaging helps
  patients take medication safely
• Target ClearRx packaging helps patients manage
  their medications
• colored rings help patients identify medications
  intended for each family member
• clear, easy-to-read label for patient
  administration instructions and cautions
• includes a pullout patient information card or
  printout

Learn more about the Target label design
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Innovations to Promote Safety

• In hospital pharmacy, integrated computerized
  filling systems allow institutions to
• improve efficiency
• redirect resources

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Medication Error and Adverse Drug Reaction
Reporting Systems

• The first step in prevention of medication errors
  is collection of information
• Fear of punishment is a concern with errors
• people may decide not to report an error at all
• allows the same error to occur again and again
• Anonymous (no-fault) reporting systems have been
  established
• focus on fixing the problem, not fixing the blame

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State Boards of Pharmacy

• More than 20 states have mandatory
  error-reporting systems
• most state officials admit medical errors are
  still under-reported mostly because of fear of
  punishment
• Some states have worked to reduce the fear of
  reporting
• allow pharmacists to document errors and
  error-prone systems without worry of punishment
• most boards of pharmacy will not punish
  pharmacists for errors

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State Boards of Pharmacy

• Pharmacy technicians are an integral part of the
  error identification, documentation, and
  prevention process
• The final and most important piece of medication
  error reporting is informing the patient that a
  medication error has taken place
• commonly the task of the pharmacist

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State Boards

• The circumstances leading to the error should be
  explained completely and honestly
• Patients should understand
• the nature of the error
• what if any effects the error will have
• how they can become actively involved in
  preventing errors in the future
• People are more likely to forgive an honest error

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Joint Commission on Accreditation for Healthcare
Organizations

• Organizations can create a centralized point
  through which all members may channel error
  information safely
• The Sentinel Event Policy was created by the
  Joint Commission on Accreditation for Healthcare
  Organizations (JCAHO) in 1996
• A sentinel event is an unexpected occurrence
  involving death or serious physical or
  psychologic injury

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Joint Commission on Accreditation for Healthcare
Organizations

• When a sentinel event is reported, the
  organization is expected to
• analyze the cause of the error (perform a root
  cause analysis)
• take action to correct the cause
• monitor the changes made
• determine whether the cause of the error is
  eliminated
• Accreditation of hospitals depends on
  demonstrating an effective active errorreporting
  system

Learn more about the Joint Commission
International Center for Patient Safety