The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) has defined medication errors (MEs) 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 health care professional, patient, or consumer.” American Society of Hospital Pharmacists guidelines for MEs stated that incidence of MEs is not exactly known because of variations in different definitions of ME, different methods, or subject populations. In India,
Study Shows in Uttarakhand and Karnataka have documented ME rate to be as high as 25.7% and 15.34%, respectively, in hospitalized patients. Unfortunately, most of the MEs remain undetected, if clinical significance or outcome does not adversely affect the patient. While some of the MEs also result into serious morbidity or mortality and have a significant economic impact on the patient and health care system.
MEDICATION MISADVENTURE.
- ADVERSE DRUG EVENTS (ADES): An ADE is the next broadest term. It refers to any injury caused by a medicine. An ADE refers to all ADRs, including allergic or idiosyncratic reactions, as well as medication errors that result in harm to a patient.
- ADVERSE DRUG REACTIONS (ADRS): refer to any unexpected, unintended, undesired, or excessive response to a medicine. Drug-drug interactions can also fall into the category of ADRs.
- A MEDICATION ERROR is any preventable event that has the potential to lead to inappropriate medication use or patient harm.
MEDICATION ERRORS CAN OCCUR ANY WHERE
PRESCRIBING - RE PACKING - DISPENSING - ADMINISTERING - MONITORING
TYPES OF MEDICATION ERROR
Prescribing Error
Incorrect drug selection (based on indications, contraindications, known allergies, existing medication therapy, and other factors), dose, dosage form, quantity, route, concentration, rate of administration, or instructions for use of a medication product ordered or authorized by Physician
Omission Error
The failure to administer an ordered dose to a patient before the next scheduled dose, if any.
Wrong Time Error
Administration of medication outside a pre-defined time interval from its scheduled administration time.
Improper Dose Error
Administration to the patient of a dose that is greater than or less than the amount ordered by the prescriber or administration of duplicate doses to the patient. Example: one or more dosage units in addition to those that were ordered.
Wrong Medication - Preparation Error
Medication product incorrectly formulated or manipulated before administration.
Wrong Administration Technique Error
Inappropriate procedure or improper technique in the administration of a medication. Example: wrong route/site or rate of administration
Monitoring Error
Failure to review a prescribed regimen for appropriateness and detection of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy.
Compliance Error
Inappropriate patient behavior regarding adherence to a prescribed medication regimen.
Other Medication Error
Any medication error that does not fall into one of the above pre-defined categories.
Factors that contribute to Medication Errors
Incomplete information about the patient.
• Unclear communication of medication order: Example; verbal & telephone order - inherently problematic: - Different accents and dialects.
- Background noise, interruptions and distractions.
- Limited short-term memory capacity.
- Unfamiliar terminology and medications.
- Spell out 1- 5 for 15 [confused with 50].
No telephone orders for: Chemotherapeutic Medications, Parenteral Nutrition, Initiation of Epidural Medications, Initiation of PCA/Narcotic Drips, Initiation of Parenteral Vasopressor Agents and Initiation of Parenteral Skeletal Muscle Relaxants.
- Lack of unit dose system.
- Lack of independent check before dispensing.
- Lack of computer warning about excessive dose.
- Ambiguous medication references.
- Conflicting requirements for staff competency.
- Warning not placed prominently on syringe.
- Environmental factors (stress, noises…etc).
- Medication storage stock standardization and distribution.
- Device acquisition and use.
- Lack of patient education.
Most Frequent Serious Medication Errors Occur With
· Insulin
· Infusion Devices
· Patient Controlled Analgesia (PCA)
· Parenteral Narcotics
· Anticoagulants (Heparin, Warfarin)
· Cancer Chemotherapy
· Neuromuscular Blockers
· Conscious (Procedural) Sedation
· Concentrated Electrolytes (potassium, magnesium and phosphate)
HOW TO PREVENT MEDICATION ERRORS
· Accept that errors will occur; slips, lapses and mistakes will happen.
· Redesign the system.
· Focus on the system, not the people.
· Everyone is involved in safety (individual practitioners & organizational leadership).
· Make the medication errors visible.
· Minimize the consequence of medication errors.
· Report, analyze and share medication error incidents.
· Promote a Culture– in reporting medication errors.
· Adopt a system-oriented approach to medication error reduction such as: (time-out, & technology confirmation).
· Use technology effectively such as:
- Implement Computerized Physician Order Entry (CPOE).
- Use of Automated Dispensing Cabinets.
- Use of Pharmacy Dispensing Robotics.
- Use of Barcoding in medication and patient identification.
- Use of Smart Infusion Pumps.
· Implement a unit dose system.
· Have the Pharmacy supply High-Alert intravenous medications and Do Not store concentrated electrolytes solutions (potassium, magnesium, and phosphate) on patient care units.
· Use special procedures and written protocols for the use of High-Alert Medications.
· Ensure the availability of Pharmacist during patient care rounds.
MONITORING MEDICATION ERRORS
- Ongoing quality improvement programs for monitoring medication errors are needed. Medication errors should be identified and documented and their causes studied in order to develop systems that minimize recurrence.
- Several error monitoring techniques exist: (e.g. anonymous self-reports, incident reports, critical incident technique and disguised observation audits).
High Alert Medications
Medication that have a higher likelihood of causing injury if they are misused. Errors with these medications are not necessarily more frequent – just that their consequences may be more devastating.
Example
· Adrenergenic agonists (e.g., Epinephrine, Phenylephrine, Norepinephrine)
· Adrenergenic antagonists (e.g., Propranolol, Metoprolol, Labetalol)
· Anesthetic agents, general, inhaled, and IV (e.g., Propofol, Ketamine)
· Antiarrhythmic, IV (e.g., Lidocaine, Amiodarone)
· Cardioplegic solutions
· Chemotherapeutic agents, parenteral and oral
· Dextrose hypertonic, 20% or greater
· Dialysis solutions, peritoneal and hemodialysis
· Epidural or Intrathecal medications
· Hypoglycemics, oral
· Inotropic medications (e.g., Digoxin, Milrinone)
· Liposomal forms of drugs (e.g., Liposomal Amphotericin B)
· Moderate sedation agents, IV (e.g., Midazolam)
· Moderate sedation agents, oral, for children (e.g., Chloral Hydrate)
· Narcotics / Opiates, IV, transdermal, and oral (including liquid concentrates, immediate and sustained-release formulations)
· Neuromuscular blocking agents (e.g., Succinylcholine, Rocuronium, Vecuronium)
· Antithrombotic agents (anticoagulants), including Warfarin, Low- Molecular-Weight Heparin, IV Unfractionated Heparin, Factor Xa Inhibitors (Fondaparinux), Direct thrombin inhibitors (e.g., Argatroban, Lepirudin, Bivalirudin), Thrombolytics (e.g., Alteplase, Reteplase, Tenecteplase) and Glycoprotein IIb / IIIa Inhibitors (e.g., Eptifibatide)
· Radiocontrast agents, IV
· Total parenteral nutrition solutions
Actions That Can Be Taken In Clinical Areas
- Risk awareness – Be aware of high alert products in your area.
- Review Floor Stock to reduce availability of items, as well as, quantities. • Use of shelf labeling which incorporates TALLman lettering.
- Separate storage for easily mistaken medicines.
- Additional product labels.
- Read the label three times (RL3).
- Insure proper and correct programming of infusion pumps.
- Independent double checking system (e.g., IV medication and infusion pumps).
- Standardize the prescribing/order entry/IV infusion labeling/ pump settings.
- Know the medications that you administer e.g., dose, route, frequency, effect, common adverse effects, & monitoring (laboratory & clinical).
Look-Alike Medications
- These refer to names of medications, which due to their spelling, may look similar to other medications’ names, and the distribution/administration of these medications may be prone to errors. Also refer to product labeling/packaging.
Example : Prozac ® and Proscar®
Sound-Alike Medications
- These refer to names of medications, which due to their pronunciation, may sound similar to other medications’ names, and the distribution/administration of these medications may be prone to errors.
Example :Dianben ® and Diovan®
General Recommendations for Preventing Medication Name Mix-ups
- Maintain awareness (e.g. FDA).
- Insure update of IT Systems (e.g, Computer systems, Smart Pumps, Automated Distribution Cabinets, etc.) to incorporate safety measures.
- Annual review of anything related to medication process.
- Consider the possibility at time of Formulary addition.
- Several preventative strategies exist to help reduce the chance of these errors, one of which is Tall Man Lettering.
- Examples of Tall Man Lettering:
o Chlorpromazine …ChlorproMAZINE
- Chlorpropamide ... ChlorproPAMIDE
- Store in different locations in pharmacies and patient care units.
- Involve patients and their caregivers.
- Develop strategies to overcome illegible prescribing:
- Printing (NOT writing) of medication names and dosages.
- Computerize prescribing.
- Preprinted orders or prescriptions as appropriate.
- Indication for use to be included on the prescription.
Encourage reporting of errors.
Implement Policies which:
Minimize verbal and telephone orders.
Continue to employ independent double checks in the dispensing and administration processes.
Barcoding, Automated Distribution Cabinets and Robotics.
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