Medication errors
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The document discusses medication errors, defining them as preventable events that may lead to inappropriate medication use or patient harm. It outlines various types of errors, including prescription, transcription, dispensing, and administration errors, along with their causes and statistics related to their prevalence. Additionally, it emphasizes the importance of proper documentation, reporting of errors, and strategies to reduce medication errors in clinical settings.
![• The national co‐ordinating council for medication
error reporting and prevention[NCCMERP] defines a
medication error as follows;
"A medication error is 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.
• Errors mayoccur at anytime, from the prescription to
consumption of the medicines by the patient.](https://image.slidesharecdn.com/medicationerrorsmom8-191124143541/85/Medication-errors-2-320.jpg)
Medication errors
- 1. MEDICATION ERRORS (Department of Clinical Pharmacology, Jaypee Hospital-Noida) Dr.Irfanul Haque Clinical Pharmacologist
- 2. • The national co‐ordinating council for medication error reporting and prevention[NCCMERP] defines a medication error as follows; "A medication error is 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. • Errors mayoccur at anytime, from the prescription to consumption of the medicines by the patient.
- 3. MEDICATION ERRORS Errorscommitted by both experienced & inexperienced staff • Errors mainly occursdue to- – Lackof knowledge – Unclear labeling of drug – Misidentification ofpatient – Mental lapsesor – Verificationerrors
- 4. Epidemiology • Interesting but horrifyingfact- •-More people in USAdie in agiven year asa result of medicalerrors than from motor vehicle accidents,breast cancers,or AIDS • Numbers reported canbe lessdueto- Small%of errors & adverse drug events detected, even smaller number arereported Most studies have looked errors only in inpatient settings
- 5. Causes of Errors • Overload/Weekends • Too many patients • Lack of Concentration • Double check not possible • Shortage of staff • Illegible Prescription • Human Errors • Abbreviations • Verbal Orders • Look alike Sound alike drugs • Wrong dosage calculations
- 6. According to ASHP(american society of hospital pharmacist) gui delines, medication error can be catagorized into 11 types • 1.prescribing error • 2.omission error • 3.improper dose errOr • 4.unauthorized drug error • 5.deteriorated drug error • 6.wrong time error • 7.wrong dosage form error • 8.wrong drug preparation error • 9.wrong administration technique error • 10.monitoring error • 11.compliance error
- 7. • Prescription Errors • Transcription Errors • Indenting Errors • Dispensing Errors • Administration Errors • Documentation Errors • Monitoring Errors
- 8. Prescription Errors A prescription error occurs at the time where Doctor prescribe drugs for a specific patient. Prescription error may include the following 1. Lackof knowledge of the prescribeddrug, dose,patient details 2. Illegiblehandwriting 3. Inaccurate medication historytaking 4. Inappropriate useofdecimal points 5. Useof abbreviations(e.g MgSo4, AZT) 6. Useof verbal orders 7. Therapeutic Duplication 8. Drug Drug Interaction or Drug food interaction 9. Drugs order in small letters
- 9. Illegible Handwriting Write complete and clear order with Drug name Dosage form, Strength, Dose, Route, frequency
- 10. Reducing Prescription Errors Computerized physician order entry(CPOE) system bythe help of Clinicalpharmacist reduces the errors.
- 11. Transcription Errors • Transcription is a process of making an identical copy of prescription in the medical records. Error that occurs during this process is known as Transcription Error. Transcription Errors are follows- 1. Several sheets of paper and stages from physician’s order 2. Incomplete or illegible prescriber orders 3. Wrong Drug dose 4. Wrong Route or frequency 5. Wrong Patient 6. Delay in Transcription. Note –Transcription staff has to high light High risk medicine in drug chart
- 12. Indenting Errors • Error that occurs during the process of ordering drugs through Computer system Indenting errors includes- 1. Wrong Drug 2. Wrong dose 3. Wrong quantity 4. Delay in Indenting
- 13. A dispensing error is a discrepancy between a prescription and the medicine that the pharmacy delivers to the patient Most Prevalent Dispensing Errors are- 1.With Look alike and sound alike drugs 2.Failure to identify drug interactions or contraindications 3.Dosage miscalculations
- 14. Dispensing errors Others Dispensing errors Wrong Drug Wrong Dose Wrong Patient Delay in Dispensing
- 15. Reducing Dispensing Errors • Ensuringasafe dispensingprocedure • Separatingdrugswith similarnameor appearance(LASA Drugs) • Useof TALLMANlettering to emphasizethe spellingof drug namesin medication storage areas(e.g. lamIVUDine & lamOTRIGine) • Unit dose medicationdispensing • Awareness of high risk Medication like potassium chloride and cytotoxic agents
- 16. Administration Errors Discrepancybetween drug receivedby patient & drug therapy intended byprescriber • Errorsof omission -the drug isnot administered • Incorrectadministration technique & administration of expired preparations • Deliberate violation ofguidelines
- 17. Incorrect Administration technique • SC injection administered too deep • IV drug is allowed to infuse via gravity instead of using IV pump • Instilling eye drops in wrong eye
- 18. Contributing Factors • Failureto checkpatient’s identity prior to administration • Environmental factors such anoise, interruptions, poor lighting • Wrong calculation to determine the correct dose
- 19. Reducing Administration Errors • Checkingpatient’s identity. • Ensuring dosage calculations arecross checkedindependently by another health care professional before drugisadministered • Ensuringmedication given at correct time • Minimizing interruptions during drug Administration
- 20. Documentation Errors • Allergy Documentation • High light of High risk medication • Administration without counter sign in high risk medication • Verbal order not Documented
- 21. Monitoring Errors • After administration of Drugs to patient, Patient has to monitor for therapeutic response of Drugs. • Monitor the patient after Discharge from Hospital.
- 22. Medication Errors Categorization Category Event A Circumstances or event that has a capacity to cause error. B Error occurred but didn’t reach the patient. C An error occurred that reached the patient but did not cause any harm. D An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and /or required intervention to preclude harm. E An error occurred that may have contribute to or resulted in temporary harm to the patient and required intervention.
- 23. Category Event F An error occurred that may have contribute to or resulted in temporary harm to the patient and required transfer to other unit/critical care. G An error occurred that may have contribute to or resulted in permanent harm of the patient. H An error occurred that required intervention to sustain life. I An error occurred that may have contribute to or resulted in patient.
- 24. Policy on reporting of Errors. • When an error is identified, it shall be reported on a “INCIDENT ERROR REPORT FORM” by nurse in charge and the doctor on duty immediately. • Reporting of an error must be part of the ordinary routine. its non- punitive so that staff does not have to be afraid of repercussions. • Continuous monitoring and frequent assessments shall be done for the all patients. • A Medication Error form shall be signed with name by the reporting person. • The medication error form shall be submitted to the Clinical Pharmacologist.
- 25. Exercise-1 Following statement is true or false.. 1.Inj.Colistim 300mg SC Once daily 2.Tab.Atorvastatin 20mg PO/OD at 10 am. 3.Tab.Metrogyl 500mg PO/TDS. 4.Inj.Clexane 0.4mg SC/OD. 5.Inj.Rantac 150mg IV/BD. 6.Inj.Zosyn 4.5 mg IV/TDS. 7.Inj.Clexane 0.4ml IV/BD. 8.Inj.Zyrop 4000 IU IV/OD. 9.Inj.Ciplox 500mg IV/BD. 10.Inj.Oflox 200mg IV/BD.
- 26. Exercise-2 • Tab.Levoflox 750mg PO/BD • Tab.Dolo 650mg PO/TDS and Inj.Perfalgan 1 gm IV/QID • Tab.Pan D and Tab. Domperidone • Tab.Metpure and Tab Embeta XR.
- 27. Exercise-3 • Inj.Caspofungin 50mg in 100ml 5% Dextrose. • Inj.Cordarone 200mg in 100ml NS. • Inj.Fungisome 50mg in 100ml 5% Dextrose.
Editor's Notes
- #14: such events may be related to professionals, heath care products, procedure and systems, including prescribing, order communication, product labeling,dispensing,distribution,admnistration, education,monitoring and use.