Medication error- Etiology and strategic methods to reduce the incidence of Medication Errors
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The document discusses medication errors, defining them as preventable events leading to inappropriate medication use or patient harm. It outlines factors contributing to errors related to healthcare professionals, patients, and work environments while highlighting high-risk medications and areas for errors. Suggested prevention strategies include training, adherence to protocols, proper communication, and involvement of patients in medication management.
Medication error- Etiology and strategic methods to reduce the incidence of Medication Errors
- 2. Medication Errors "A medication error is any preventable event that may cause or lead to inappropriate medication use or patient ā¢ Any preventable event that may cause or lead to in inappropriate medication use or patient harm due to : ļ¶Wrong patient ļ¶Wrong medication ļ¶Wrong dose ļ¶Wrong route ļ¶Wrong time ļ¶Wrong documentation
- 4. Types of Medication Errors ā¢ Prescription error ā¢ Transcription error ā¢ Indenting error ā¢ Dispensing error ā¢ Administration error ā¢ Monitoring error
- 5. Error Factors often Arises in medication administration ļ±Poor communication ļ±Carelessness ļ±Multiple interruptions ļ±Stress ļ±Lack of knowledge ļ±working conditions
- 7. Causes of Errors Factors associated with health care professionals ā¢ Physical problems ,Tired, unwell, stressed etc. ā¢ Lack of protocols or policies ā¢ Lack of training ā¢ Verbal rather than written culture ā¢ Time pressure & Staff turnover ā¢ Poor communication with healthcare staffs ā¢ Lack of support from other healthcare professionals
- 8. Causes of Errors Factors associated with patients ā¢ Lack of patient awareness of medicines ā¢ Patient characteristics (e.g., personality, literacy and language barriers) ā¢ Complexity of clinical case, including multiple health conditions, polypharmacy and high-risk medications
- 9. Causes of Errors Factors associated with the work environment ā¢ Workload and time pressures ā¢ Distractions and interruptions (by both primary care staff and patients) ā¢ Lack of standardized protocols and procedures ā¢ Insufficient resources ā¢ Issues with the physical work environment (e.g., lighting,temperature and ventilation)
- 10. Causes of Errors Factors associated with medicines ā¢ Naming of medicines ā¢ Labelling and packaging ā¢ Storage of medicine
- 11. High Risk Areas for Medication Errors ā¢ High alert medications ā¢ High risk patients ((Pregnant, Elderly, HIV, Transplant Patients, Anticoagulants, Pediatric Patients, Psych Patients) ā¢ High risk diseases ā¢ Infusion pumps (High Risk Medications, Incorrect Pump Programming, Calculation / Concentration Errors, Wrong Medication) ā¢ Verbal orders ā¢ Abbreviations ā¢ Look-alike drugs
- 12. Prominent reasons enhancing Medication Error ļ§ Look Alike & Sound Alike drugs ļ§ Non compliance in Drug Standard Timing ļ§ Units while prescribing drugs ļ§ Prohibited Abbreviations ļ§ Illegibility in prescription ļ§ Unavailable Drug Information ļ§ Independent Cross Checking ļ§ High Risk Medications ļ§ Medication Reconciliation and its documentation
- 19. Medication Errors : High Alert Medications ļ± Chemotherapeutic drugs ļ± Potassium Chloride ļ± Opiates and narcotics ļ± Insulin and oral hypoglycemic agents ļ± Anticoagulants (Heparin) ļ± Antihypertensive agents ļ± Psychiatric medication ļ± Anticonvulsants ļ± Cardiac drugs
- 20. Analysis of Administration Error 0 10 20 30 40 Documented before administration leads to missed dose Staff nurse did not cross check the file before hand over Handover was not taking without checking the medication Wrong Initial time Cross checking of prescribed dose before administration Instead of half tablet, full tablet administered Patient file not taken to the bedside during administration. Lack of drug information for the nurses Administer the medication at the wrong time Lack of monitoring and supervisory mechanism from the TL/In charge for costly medicines Escalation not done New joined staff COMMUNICATION GAP
- 22. Case Study
- 23. Accidental administration of epinephrine instead of midazolam A 50-year-old women who was accidentally administered epinephrine instead of midazolam during colonoscopy preparation. The patient originally presented to the hospital with a history of abdominal pain and altered bowel habits. A colonoscopy was scheduled following administration of what was believed to be midazolam 5 mg. She then started to complain of chest tightness, difficulty breathing, and generalized tremors. It was soon discovered that a medication error occurred and the patient was instead administration 0.25 mg of epinephrine instead of midazolam. The procedure was postponed for several days until the patient recovered.
- 24. ļ§ A root cause of the error revealed that the epinephrine ampule was mistakenly placed in the box with the midazolam in the pharmacy following an instance where a previous patient did not require the medication. ļ§ Ampules of both medications were similar in size, shape, and color. As a result, the hospital initiated new procedures to ensure regular reviews of drug containers and their contents and double checking medication names before administration.
- 25. Unintentional administration of insulin instead of influenza vaccine 5 adult patients unintentionally received insulin instead of the influenza vaccine. The mix-up occurred at a public school clinic in Missouri and was discovered following an investigation from the government. Officials learned that a school nurse inadvertently administered Humalog U-100 insulin instead of the influenza vaccine. Acute hypoglycemia was reported in all 5 patients who received the insulin with varying degrees of symptoms.
- 26. ļ§After the first 2 patients complained of sweating and lightheadedness, the nurse reported the incidents to the supervising nurse, but did not stop administering vaccines. Two later patients would require hospitalization for their symptoms, one of which was documented to have a blood glucose level of 23 mg/dL. ļ§The investigation revealed that the influenza vaccine vial was kept in the nurseās office refrigerator along with a 10 mL vial of Humaog U-100 insulin; they were found to not be stored in separate, labeled containers or bins.
- 27. MEDICATION ERROR ANALYSIS MONITORING TRAINING Medication Error MANPOWER DOCUMENTATION Shortage of doctors Infrequent audits No over sight by Nursing TL Lack of knowledge & Staffs untrained on Medication administration Doctors are not trained on medication reconciliation Staffs not sensitised about medication error Documented before administration New Nursing staff Joined Wrong transcription No Documentation Wrong documentation No over sight of Doctors notes Cross checking was not happen COMMUNICATION Hand Over communication was not proper Communication Gap between doctors and Nursing ; Nursing , Pharmacist and Doctors PRESCRIPTION Escalation not happen Incomplete Prescription Illegible handwriting Special instruction was not written Shortage of Pharmacist Pharmacist are not trained
- 28. Ways to Prevent Medication Errors Follow and practice ā Rights of Drugā administration, the ways to prevent these errors are: ļ± Donāt administer any drug without a doctorās order. ļ± Always check the label to identify a drug. Donāt rely on the drugs color, shape, or location in the medication case. ļ± Check the label against the doctors order and the patientās medication administration record (MAR) two times: when obtaining the drug, when preparing the dose.
- 29. ļ± If you have any doubts about the drug you are giving, call the doctor ļ± Check expiration dates, and return out dated drugs to the pharmacy. ļ± Ask senior nurse to double check your dosage calculations. ļ± Donāt give drugs another nurse has prepared. ļ± The nurse should have verified the dosage before giving the drug-and she should to followed a basic administration rule, āIf you donāt know a drug and itās dosage, donāt give it until you find out ļ± Donāt try to interpret illegible handwriting even in ask the physician. ļ± Identify the patient by his ID band- donāt just ask his name or check his bed number. ļ± Use appropriate documentation on the MAR (Medication Administration record) helped to prevent errors.
- 30. Educating health care providers and patients ļ§ Educating primary care providers about common causes of medication errors ļ§ Providing simple tools to assist primary care providers in safe medication prescribing and use process ļ§ Considering how patients can be actively involved in medicine management ļ§ Providing patient engagement tools to address non-adherence Implementing medication reviews and reconciliation ļ§ Ensuring that pharmacists actively review prescriptions ļ§ Encouraging and supporting use of medication reconciliation by clinicians Using computerized systems ļ§ Computerized provider order entry with decision support may be particularly effective when targeted at a limited number of potentially inappropriate medications and when designed to reduce the alert burden by focusing on clinically-relevant warnings.