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Preventing Medication Errors

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Title: Preventing Medication Errors


1
Preventing Medication Errors
  • August 2009
  • Joe Manganelli, PharmD, MPA, RPh

2
Objectives
  • Define medication errors
  • Discuss financial impact- medication errors
  • Factors that contribute to medication errors
  • Some causes of medication errors
  • Groups most at risk
  • Prevention of medication errors

3
Definition
  • A medication error is any preventable event that
    may cause or lead to inappropriate medication use
    or patient harm.
  • Such events may be related to professional
    practice, health care products, procedures, and
    systems, including prescribing order
    communication product labeling, packaging, and
    nomenclature compounding dispensing
    distribution administration education
    monitoring and use.
  • National Coordinating Council for Medication
    Error Reporting and Prevention (NCC MERP)

4
The Problem
  • Medication errors continue to be one of the
    most frequent causes of preventable harms in
    health care.
  • Ambiguous medical notations are one of the most
    common and preventable causes of medication
    errors.
  • Drug names, dosage units, and directions for
    use should be written clearly to minimize
    confusion.

5
Statistics
  • Institute of Medicine's (IOM) report, Preventing
    Medication Errors estimates that 1.5 million
    Americans are harmed by preventable adverse drug
    events each year, and hospitalized patients
    suffer an average of 1 medication error per day.
  • Fortunately, most medication errors have little
    potential for harm, but every error is
    potentially tragic and costly.

6
IOM Report-To Err is Human
  • Noting that at least 1 in 4 of these errors is
    preventable, the IOM called on pharmacists,
    physicians, and government officials to take
    steps to reduce the rate of medication mistakes.
    To address the problem, the report called on the
    government to speed electronic prescribing by
    encouraging compatibility among the varied
    computer programs used by doctors, hospitals, and
    drugstores.

7
IOM Report- To Err is Human
  • Suggested stronger oversight by the FDA to
    address safety issues connected with drug
    packaging and labeling, similar named drugs and
    post marketing surveillance by doctors and
    pharmacists.

8
Financial Impact
  • On a per patient basis, a single serious drug
    error can add more than 8750 to the average
    hospital bill.
  • Treating injuries caused by medication errors
    costs more than 3.5 billion a year in hospitals
    alone.

9
Financial Impact
  • Medication error litigation can result in
    compensation awards.
  • CMS- Medicares stance on medical errors
  • Effective October 2008, Medicare no longer paying
    to treat preventable medical errors.

10
Contributing Factors
  • Volume of prescriptions dispensed continues to
    rise
  • Increased pharmacist workload
  • Short staffing
  • Not enough time to counsel patients
  • Discussing the drug, its indication and how it is
    taken should be a final check

11
No simple solution
  • Computer Systems
  • Can prevent errors
  • Can cause errors
  • A culture of safety should be encouraged so that
    staff is willing to discuss strategies in
    reducing errors
  • Identify prevent potential computer-entry errors

12
Research
  • A study found that 57 percent of medication
    errors made in family physicians' offices could
    have been prevented by electronic medical records
    (EMR)or computerized physician order entry
    (CPOE).

13
The Medication Process
  • Medication errors often occur in one or more of
    the following medication stages
  • Prescribing / Transcribing
  • Dispensing / Distribution
  • Administration
  • Incomplete data poses risk for medication errors
  • Unknown allergies, other drugs, previous
    diagnoses
  • Errors with computer entry include
  • Omission of drug, Improper dose or quantity

14
Causes of Medication Errors
  • Abbreviations
  • ISMP has identified error-prone abbreviations.
    Some examples include
  • AS, AD, AU for OS, OD, OU
  • QD for QID, QOD for QID
  • U or IU for 0 or 10, or IV
  • Bad handwriting
  • Verify illegible orders

15
LASA Drugs
  • Look Alike- Sound Alike Drugs
  • It has been reported that up to 25 of all
    reported errors are linked to LASA confusion
  • Read Rx back to prescriber to verify
  • include the drugs purpose/ indication
  • Affix name alert stickers to bins where LASA
    drugs are stored
  • store drugs separately

16
Examples of LASA drugs
  • Aricept - Aciphex
  • Actos- Actonel
  • Celebrex - Celexa -Cerebyx
  • Darvon - Diovan
  • hydroxyzine - hydralazine
  • Lasix - Luvox
  • Paxil Plavix
  • Prednisone - Primidone

17
LASA drugs examples
  • Navane- Norvasc
  • Novolin- Novolg, Humulin Humalog
  • (one can be selected for the other on a computer
    screen)
  • Tramadol Trazodone
  • Vincristine Vinblastine
  • Wellbutrin SR- Wellbutrin XL
  • (use of suffixes can cause confusion)

18
Groups Most at Risk
  • Healthcare literacy and cultural competency
  • People with low health literacy have a greater
    number of medication errors
  • Geriatric patients
  • The elderly take more medications and at a higher
    risk for medication errors
  • Many medications should be avoided by elderly
    patients

19
Health Literacy
  • Some medication errors occur because patient
    misuse of a drug
  • poor understanding of the directions for proper
    product use
  • Instructions should be delivered in a culturally
    sensitive format
  • Pharmacies should use auxiliary stickers with
    pictures, such as for the eye, for the ear.

20
Transitions of Care
  • The potential for medication errors increases
    when patients transition in the healthcare system
    or return home.
  • Accurate and complete medication reconciliation
    can prevent numerous prescribing and
    administration errors.

21
Transitions of Care
  • Use of a patient medication list is advised
  • Include start and stop dates
  • Reconcile pre-admission list to discharge list.
    Follow-up on discrepancies.

22
Transitions of Care
  • Develop list of medications currently taken
  • Develop list of medications prescribed
  • Compare the two lists
  • Make clinical decisions comparing the two lists
  • Communicate findings to practitioner and patient
  • Medication reconciliation errors 66 occurred
    during transfer to another level of care, 22
    occurred during admission, 12 at discharge.
  • JCAHO Sentinel Event Alert Issue 35, January 2006

23
Medication Reconciliation
  • Medication reconciliation is the process of
    comparing a patients medication orders to all of
    the medications that the patient has been taking.
    This reconciliation is done to avoid medication
    errors such as omissions, duplications, dosing
    errors or drug interactions.
  • Joint Commission National Patient Safety Goal 8-
    a discharge list of medications should be given
    and discussed with the patient.
  • Route, frequency and reason for use

24
The role of working conditions
  • Workflow design
  • Review Rx process from beginning to end
  • Physical environment
  • Lighting, heat, noise
  • Organizational factors
  • Strive for a distraction-free work station,
    especially for prescription verification

25
Prevention of Medication Errors
  • Utilizing pharmacists as integral members of the
    patient care team as experts in medication-use
    safety and quality.
  • Encouraging patients to keep an up-to-date list
    of all their medications
  • Consulting/counseling with patients about their
    medications
  • Promote a culture of safely in healthcare
    organizations- additional training?

26
Prevention of Medication Errors
  • Barcoding of medications can reduce hospital
    pharmacy dispensing errors that typically involve
    the incorrect medication, strength, or dosage
    form. Barcoding implementation was cost
    effective.
  • Medication errors can be reduced by electronic
    medical records and computerized physician order
    entry.
  • Maviglia, S.M., Yoo, J.Y., Franz, C., and others.
    (2007, April). "Cost-benefit analysis of a
    hospital pharmacy bar code solution." Archives of
    Internal Medicine 167, pp. 788-794.

27
Prevention of Medication ErrorsPatient
Instructions
  • Keep an UPDATED list of all medications taken,
    including Rx, OTCs, nutritionals.
  • Ask to clarify anything not understood, or if
    anything looks different on refill.
  • Variation in generic drugs
  • Request written information on drug products.

28
Patient Instructions
  • Find out if any medications, food or beverages
    should be avoided (eg allergies).
  • Telling your healthcare provider how you actually
    take your medication, especially if this is
    different that the originally prescribed
    directions.

29
Patient Instructions
  • Be safe. Be sure. Read the label.
  • Check your name
  • Check the directions
  • Check any warnings
  • Call Poison Control if needed

30
Preventing Errors
  • Bottle labels contain the shape and color of the
    pills
  • Keep drug information up- to- date
  • Triple check prescriptions before dispensing
  • Avoid ambiguous abbreviations

31
Preventing Errors
  • Recent FDA action
  • New warning on Botox, Myobloc and similar
    products about the possibility of life
    threatening breathing and swallowing problems.
  • FDA is changing the generic names for both
    products to avoid medication errors
  • Botox- onabotulinumtoxinA
  • Myobloc- rimabotulinumtoxinB

32
Pharmacist Survey
  • Drug Topics, July 2009 Pharmacist-Driven
    initiatives- 4 errors per 250 scripts
  • Counseling- provides an essential safeguard
    against medication errors.
  • Better Time Management- less time multi-tasking -
    important to accurate drug dispensing
  • Taking breaks- reduces fatigue, prevents stress
    related errors
  • Filling Technology-bar coding minimizes errors

33
Summary
  • Preventing medication errors
  • Review / improve workflow, medication processes
  • consider use of barcodes
  • computerize prescribing
  • Pay attention to LASA drugs
  • Avoid unapproved abbreviations
  • Medication reconciliation- transitions of care
  • Counsel patients

34
References
  • Grace M. Kuo, Pharm.D., Robert L. Phillips, M.D.,
    Deborah Graham, M.S.P.H., and John M. Hickner,
    M.D., in Quality and Safety in Health Care 17,
    pp. 286-290.
  • Agency for HealthCare Research and Quality
    www.ahrq.gov
  • Institute for Safe Medication Practices
    www.ismp.org
  • Food and Drug Administration www.fda.gov/cder
  • The Institute of Medicine www.iom.edu

35
References, continued
  • Am J Health-Syst Pharm Vol 66 May1, 2009
    www.ashp.org
  • Using medication reconciliation to prevent
    errors. The Joint Commission. www.jointcommission.
    org/sentinelevents
  • Center for Safety and Clinical Excellence,
    Cardinal Health www.cardinalhealth.com
  • www.safemedication.com
  • www.nccmerp.org
  • www.1-800-222-1222.info poison prevention tips

36
Thank you!
  • Questions?
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