Medication error
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The document discusses types of medication errors and strategies to reduce errors. It defines medication error and outlines types including prescribing, dispensing, and administration errors. Examples of errors involving look-alike drugs and illegible handwriting are provided. The document also describes two error reduction strategies: using tall man lettering to distinguish similar drug names and issuing medication error alerts when errors occur.
Medication error
- 1. MEDICATION ErrOr (ME) Prepared by, Hema Latha Sinniah Pegawai Farmasi U41 PKD Sabak Bernam
- 2. Definition What to/ not to report ME Types ME Reporting Flow Chart ME Report Form ME Examples Error Reduction Strategies
- 3. Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the healthcare professional, patient or consumer NCCMERP, US DEFINATION MEDICATION ERROR . .
- 4. When errors are common, Health Care is Hazardous. We need to reduce the risk of error, predominantly by improving systems. Accepting that errors cannot be eliminated, we need to Encourage reporting Learn from errors Manage the repercussions to the patient, caregivers, and any other affected groups.
- 5. Non-punitive All levels of healthcare providers may report Involve both public and private sectors Includes hospitals, clinics, community pharmacies
- 6. Maybe related to professional practice, healthcare products, procedures and systems including: prescribing, order communication, product labeling, packaging, compounding, dispensing, distribution, administration, monitoring and use 6
- 7. Medication errors can be committed (or contributed to) by Anyone who handles medicine Physicians/doctors, dentists, pharmacists, other healthcare providers, patients, caregivers etc
- 8. Error is inevitable because of human limitations - Limited memory capacity - Limited mental processing capacity - Negative effects of fatigue and other physiological stressors
- 9. Look at systems involved in medication error Why? and not Who?
- 10. Risks that can lead to errors or near misses Sound-alike names or look alike packages Ambigous product labels Use of error prone abbreviations Error-prone functions in cpoe systems
- 11. 1. Look alike drugs which can be in terms of product size, packaging and also colour on the label, example ;
- 12. Hyoscine butylbromide 20mg/ml injection & Prochlorperazine mesylate 12.5mg/ml injection
- 13. Potassium chloride 10% w/v injection & Sodium bicarbonate 8.4% w/v injection
- 16. Simvastatin, Atorvastatin, Rosuvastatin Omeprazole,Pantoprazole,Esomeprazole Perindopril, Enalapril, Ramipril Cefotaxime, Cefuroxime Neurobion, Neurontin
- 17. 3. Illegible handwriting, which may lead to misinterpretation of doctor’s prescription such as drug’s name, dosage, frequency, example;
- 20. Medication error can be broadly classified as : Prescribing errors Dispensing errors Administration errors
- 21. Inadequate knowledge about drug interaction & contraindication Not considering individual patient factor -E.g. allergies,pregnancy,co-morbidities,other med Miscommunication(written,verbal) Documentation-illegible,incomplete,ambiguous Incorrection calculation Incorrect data entry when using computerized Physian Order Entry(CPOF)
- 22. Wrong stock selection Self-checking Incorrect storage of medicines,wrong shelf,etc Not following checking protocols Staff distraction Too many tasks at once Too few staff Poorly trained staff Bad communication between staff
- 23. Wrong patient Wrong drug Wrong time Wrong dose Wrong route Omission,failure to administer
- 24. PrescribingPrescribing errorerror Incorrect drug productIncorrect drug product selection (based onselection (based on indications, CI,knownindications, CI,known allergies, existing drugallergies, existing drug therapy), dose,dosagetherapy), dose,dosage form, quantity, route orform, quantity, route or rate of administration,rate of administration, conc, or instructions forconc, or instructions for use authorised byuse authorised by physician; illegible Rx orphysician; illegible Rx or med orders that lead tomed orders that lead to errorserrors
- 25. OmissionOmission errorerror The failure to administerThe failure to administer an ordered dose to aan ordered dose to a patient before the nextpatient before the next ordered dose or failure toordered dose or failure to prescribe a drug productprescribe a drug product that is indicated.that is indicated. The failure to administerThe failure to administer an ordered dose excludesan ordered dose excludes patient’s refusal andpatient’s refusal and clinical decision or otherclinical decision or other valid reason not tovalid reason not to administer.administer.
- 26. Wrong timeWrong time errorerror Unauthorised/Unauthorised/ wrong drugwrong drug errorerror Administration ofAdministration of medication outside amedication outside a predefined time intervalpredefined time interval from its scheduledfrom its scheduled administration timeadministration time Dispensing orDispensing or administration to theadministration to the patient of medication notpatient of medication not authorised by a legitimateauthorised by a legitimate prescriberprescriber
- 27. Dose errorDose error Dispensing or administrationDispensing or administration to pt of a dose that is > or<to pt of a dose that is > or< than amount ordered bythan amount ordered by prescriber or administrationprescriber or administration of multiple doses to ptof multiple doses to pt Dosage formDosage form errorerror Dispensing or administrationDispensing or administration to pt of a drug product into pt of a drug product in diff dosage form than thatdiff dosage form than that ordered by prescriberordered by prescriber
- 28. DrugDrug preparationpreparation errorerror Drug product incorrectlyDrug product incorrectly formulated or manipulatedformulated or manipulated before dispensing orbefore dispensing or administrationadministration Route ofRoute of administrationadministration errorerror Wrong route ofWrong route of administration of theadministration of the correct drugcorrect drug AdministrationAdministration techniquetechnique errorerror Inappropriate procedure orInappropriate procedure or improper technique in theimproper technique in the administration of a drugadministration of a drug other than wrong routeother than wrong route
- 29. DeterioratedDeteriorated drug errordrug error Dispensing or administrationDispensing or administration of a drug that has expired orof a drug that has expired or the physical or chemicalthe physical or chemical dosage form integrity hasdosage form integrity has changedchanged MonitoringMonitoring errorerror Failure to review aFailure to review a prescribed regimen forprescribed regimen for appropriateness & detectionappropriateness & detection of problems, or failure to useof problems, or failure to use appropriate clinical or labappropriate clinical or lab data for adequatedata for adequate assessment of pt response toassessment of pt response to prescribed therapyprescribed therapy 29
- 30. ComplianceCompliance errorerror Inappropriate patientInappropriate patient behavior regardingbehavior regarding adherence to a prescribedadherence to a prescribed medication regimenmedication regimen OtherOther medicationmedication errorerror Any medication error thatAny medication error that does not fall into one of thedoes not fall into one of the above predefined typesabove predefined types
- 32. 18. Medication Error (ME) Reporting Form MEDICATION ERROR (ME) REPORTING FORM Reporters do not necessarily have to provide any individual identifiable health information, including names of practitioners, names of patients, names of healthcare facilities, or dates of birth (age is acceptable) 1. Date of event Time of event Place /Location of event 2. Please describe the error. Include description/sequence of events, type of staff involved, and work environment (e.g. change of shift, short staffing, during peak hours). If more space is needed, please attach a separate page. 3. Did the error reach the patient? (Tick appropriate box) Yes No 4. Was the incorrect medication, dose or dosage form administered to or taken by the patient? (Tick appropriate box) Yes No 4 .1 Circle the appropriate Error Outcome Category (select one – see Guide for details) A B C D E F G H I 4 .2 Describe the direct result on the patient (e.g., death, type of harm, additional patient monitoring). 5. Indicate the possible error cause(s) and contributing factor(s) (e.g., abbreviation, similar names, distractions, etc). 6. What category of staff or healthcare provider made the initial error? 7. Indicate if other provider (s) were also involved in the error (category of staff perpetuating error) 32
- 33. Medication Error (ME) Report Form Hospital Pharmacy Medication Safety, Pharmaceutical Services Division,MOH www.pharmacy.gov.my
- 34. Date and time of event Type of facility Private/ government hospital/clinic/pharmacy Location of event: - ward - pharmacy - A& E - OT/ ICU etc
- 35. Description of event - sequence of events - work environment (peak hour, change of shift) - details (what? how? of the incident) Attach separate page if more space is needed
- 36. In which process error occur Prescribing/Dispensing/Administration/ Others Did error reach patient Y/N Incorrect med, dose or dosage administered or taken by patient Describe direct result on patient eg. death, admission into hospital, drugs prescribed to treat error
- 37. Did an actual error occur? Category C Circumstances or events that have the capacity to cause error Did the error reach the patient? * Did the error contribute to or result in patient death? Was the patient harmed? Did the error require an intervention necessary to sustain life ? Did the error require initial or prolonged hospitalization Was the harm temporary ? Was the harm permanent ? Category H Category G Category E Category F Was intervention to preclude harm or extra monitoring required ? Category B Category A Category I Category D NO NO NO NO NO NO NO YES YES YES YES YES NO YES YES NO YES YES Classification of Medication Error SeverityClassification of Medication Error Severity NO ERRORNO ERROR Category ACategory A Potential error, Circumstances/events havePotential error, Circumstances/events have potential to cause incidentpotential to cause incident ERROR, NO HARMERROR, NO HARM Category BCategory B Actual Error – did not reach patientActual Error – did not reach patient Category CCategory C Actual Error – caused no harmActual Error – caused no harm Category DCategory D Additional monitoring required – caused noAdditional monitoring required – caused no harmharm ERROR HARMERROR HARM Category ECategory E Treatment/Intervention required –causedTreatment/Intervention required –caused temporary harmtemporary harm Category FCategory F Initial/prolonged hospitalization –causedInitial/prolonged hospitalization –caused temporary harmtemporary harm Category GCategory G Caused permanent harmCaused permanent harm Category HCategory H Near death eventNear death event ERROR, DEATHERROR, DEATH Category ICategory I DeathDeath An error of omission does reach theAn error of omission does reach the patientpatient All ME reports should be sent to : Medication Safety Centre Pharmaceutical Services Division , Ministry of Health P.O. Box 924, Jalan Sultan, 46790 Petaling Jaya, Selangor. 19. GUIDE FOR CATEGORIZING MEDICATION ERRORS 37
- 38. Possible contributing factor (s) Example: - Sound alike or look alike drug - Look alike packaging - Different strength of same drug - Unclear instruction on Rx - Illegible handwriting
- 39. Category of staff made initial error? Other category involved Category of staff,provider or individual who discovered the error/potential error Example: Doctor, pharmacist, staff nurse, pharmacist assistant, asst medical officer, PRP, trainee MA or SN
- 40. Patient’s particulars Do not provide patient’s name Info needed = age, M or F, diagnosis Product 1 intended (prescribed)/ error brand name, generic name, dose, freq,duration, route similar packaging- manufacturer, dosage form, strength, container type
- 41. Relevant materials can be provided - copy of Rx, label of product, picture of product involved Recommendations/ preventive actions taken Reporter’s details
- 42. P.O Box 924, Jln Sultan 46790 Petaling Jaya Tel : 03- 7841 3200 Fax: 03- 79682268 Online Sistem pengurusan farmasi ME MedSC
- 44. Administrative errors Examples: no prescribers stamp no countersignature for category A medicines Medicines not stocked
- 45. Tall Man Lettering Writing part of a drugs name in upper case letters to help distinguish sound alike, look alike drugs from one another niMODIpine - niFEDIpine METOprolol - BISOprolol predniSONE – prednoso LONE Currently the Pharmacy Department has labeled the drug bins using this format
- 46. Medication Error Alert Alerts should be issued out whenever errors occur so that the information will be disseminated for others to be more careful in dealing with the medication involved. This alerts can be issued via emails, memo and also posters.
- 47. Poster of product change Circulate posters on product changes so that all pharmacy staff will know that certain medications had changed in appearance.
- 48. Colour-coded bins The bin label is differentiated according to pharmacological group. The colour coding concept is adapted from 5S Guidelines 2011 published by the Pharmaceutical Service Division, Ministry of Health Malaysia.
- 49. Prompt alert in e-HIS Prompt alert in the e-HIS were created for medications which has potential of being mistakenly prescribed by doctors. Most of the drugs involved are medication which sound alike.
- 50. Enable the healthcare providers & institutions to learn about : • Potential risks - Risk hidden in the processes used • Actual errors - Errors that happen during patient care • Causes of errors - Underlying weaknesses in systems & processes that explain why errors happened • Prevention - Ways of preventing recurrent events
- 52. THANK YOU FOR YOUR ATTENTION MEDICATION ERRORS ARE PREVENTABLE!
- 53. What are the types of medication error? Give 3 examples. What are the steps taken to overcome this error? Name 2 of them.
Editor's Notes
- #32: Voluntary reporting