Medication errors.pptx
- 2. DEFINITION The United States National Coordinating Council for Medication Error Reporting and Prevention defines a medication error 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. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”. • May occur at any time, from the prescription to consumption of the medicines by the patient • Problems & sources of medication errors are multidisciplinary & multifactorial
- 3. FACTORS THAT INFLUENCE MEDICATION ERRORS Factors associated with health care professionals • Lack of therapeutic training • Inadequate drug knowledge and experience • Inadequate knowledge of the patient • Inadequate perception of risk • Overworked or fatigued health care professionals • Physical and emotional health issues • Poor communication between health care professional and with patients
- 4. FACTORS THAT INFLUENCE MEDICATION ERRORS Factors associated with patients • Patient characteristics (e.g., personality, literacy and language barriers) • Complexity of clinical case, including multiple health conditions, polypharmacy and high-risk medications causes of medication errors Factors associated with the work environment • Workload and time pressures • Distractions and interruptions (by both primary care staff and patients) • Lack of standardized protocols and procedures • Insufficient resources • Issues with the physical work environment (e.g., lighting, temperature and ventilation)
- 5. FACTORS THAT INFLUENCE MEDICATION ERRORS Factors associated with medicines • Naming of medicines • Labelling and packaging Factors associated with tasks • Repetitive systems for ordering, processing and authorization • Patient monitoring (dependent on practice, patient, other health care settings, prescriber)
- 6. FACTORS THAT INFLUENCE MEDICATION ERRORS Factors associated with computerized information systems • Difficult processes for generating first prescriptions (e.g. drug pick lists, default dose regimens and missed alerts) • Difficult processes for generating correct repeat prescriptions • Lack of accuracy of patient records • Inadequate design that allows for human error
- 7. EPIDEMIOLOGY • Interesting but horrifying fact- - More people in USA die in a given year as a result of medical errors than from motor vehicle accidents, breast cancers, or AIDS - Majority are medication errors • Indian study of paediatric intensive care unit reported 68.5% of all errors were medication errors
- 8. EPIDEMIOLOGY • Numbers reported can be misleading due to Small % of errors & adverse drug events detected, even smaller number are reported • Inconsistencies in way the errors reported & counted • Most studies have looked errors only in inpatient settings • Most studies focus on errors of commission(fails to consider errors of omission)
- 9. CLASSIFICATION Errors When actions are intended but not performed Mistakes Errors in planning action Skill based errors (slips & lapses) Errors in executing correctly planned actions Knowledge Based errors Rule- based errors Action-based errors (slips) Memory- based errors(lapses ) Rules misapplied Bad rules Technical errors
- 10. Intension Mistakes Plan cannot reach target Intended outcome Slip/Lapse Error in implementing plan
- 11. SOURCES OF ERRORS • Incorrect transcription • Mix up of patients • Mix up of drugs • Mistakes in calculation of drugs concentration • Incorrect or missing of labelling of solutions • Wrong / omitted / passed expiry date • Difficulties in handling certain IV preparation techniques • Use of inappropriate diluents • Contamination of drugs • Wrong storage • Insufficient mixing of ingredients • Incompatibilies • Adsorption • Incorrect infusion rate • Incomplete delivery of the container contents
- 12. CAUSES OF ERRORS Errors of Omission: errors related to prescription, drug dispensing by pharmacist, drug administration by medical personnel like nurses & patient themselves • Errors of Commission: most common form of errors encountered in clinical practice, this include – 1.) Wrong phenomenon 2.) Drug interaction related 3.) Communication failure 4.) Failure to follow appropriate policies related to drug use 5.) Failure to follow drug-specific instructions 6.) Overuse of a drug(irrational drug use & polypharmacy)
- 13. CAUSES OF ERRORS 1. “Wrong” phenomenon – - Wrong drug, wrong dose, wrong substitution for a drug, wrong patient, wrong regimen, wrong route 2. Drug interaction related errors – - Food-drug interaction, drug- drug interaction or interactions with other alternative forms of medicine - Responsible for medication errors, which may lead to serious adverse events, sometimes hospitalization or death of patient
- 14. CAUSES OF ERRORS Communication failure – - Failures during the process of patient management - Includes illegible handwriting, incomplete prescribing order, vague instructions, prescription not recognized & unknown prescriber - Common errors include: ‘g’ mistaken for ‘mg’, ‘4’ mistaken for ‘U’, decimal point(‘.1’ read as ‘1’)
- 15. SWISS CHEESE MODEL Pictorial model for medication errors • Defences against error displayed as thin layers with holes that describes latent errors in system • Each layer successively represents the prescriber, pharmacist, nurse & patient related defences • Missed error successively at various defence levels, reaches the patient
- 17. EXAMPLE
- 18. Some other recognized types of medication errors- Incomplete patient information Drug information unavailable Miscommunication of drug orders Confusion in drug names Misuse of zeros & decimal points Confusion in dosing units Inappropriate abbreviations
- 19. TYPES OF ERRORS • Prescribing errors • Dispensing errors • Administration errors
- 20. PRESCRIBING ERRORS • Incorrect drug selection for a patient • Errors in quantity & indication • Prescribing contraindicated drug
- 21. FACTORS CONTRIBUTING Lack of knowledge of the prescribed drug, dose, patient details Illegible handwriting Inaccurate medication history taking Confusion with the drug name Inappropriate use of decimal points Use of abbreviations (e.g. AZT) Use of verbal orders
- 22. RISK FACTORS FOR PRESCRIBING ERRORS • Work environment & workload • Miscommunication within team • Physical & mental well being • Lack of knowledge • Inadequate training • Low perceived importance of prescribing • Absence of self awareness of errors
- 23. REDUCING PRESCRIBING ERRORS • Electronic prescribing reduces errors due to illegible handwriting • Computerized physician order entry system eliminates need for transcription orders by nursing staff
- 25. DISPENSING ERRORS • Receipt of the prescription supply of a dispensed medicine to patient • Occurs primarily with drugs having similar name or appearance • Example :lasix® (frusemide) and losec® (omeprazole) • Other potential dispensing errors include – wrong dose – wrong drug or – wrong patient
- 27. REDUCING DISPENSING ERRORS • Ensuring a safe dispensing procedure • Separating drugs with similar name or appearance • Unit dose medication dispensing • Automated medication dispensing system • Bar code medications for dispensing & administration (patient given barcoded wristband)
- 28. ADMINISTATION ERRORS • Discrepancy between drug received by patient & drug therapy intended by prescriber • Errors of omission - the drug is not administered • Incorrect administration technique & administration of incorrect or expired preparations • Deliberate violation of guidelines
- 30. CONTRIBUTING FACTORS • Failure to check patient’s identity prior to administration • Environmental factors such a noise, interruptions, poor lighting • Wrong calculation to determine the correct dose
- 31. REDUCING ADMINISTRATION ERRORS • Checking patient’s identity. • Ensuring dosage calculations are cross checked independently by another health care professional before drug is administered • Ensuring medication given at correct time • Minimizing interruptions during drug rounds
- 32. STEPS TO PREVENT MEDICATION ERRORS • Targeted physician education on optimal medication use • Inclusion of clinical pharmacists in decision making activities • Computerized order entry by prescriber & medication checking • Standardize processes & equipment • Avoid use of unknown abbreviations & symbols • Double check patients having allergies before prescribing • Check the expiry date of the drug before administration • Medication Reconciliation • Standardised ordering and administration • Training, education, and organisational interventions • Preparing medicine in well lighted room
- 33. SIX STEP APPROACH BY WHO FOR GOOD PRESCRIBING • Evaluate & clearly define patient’s problem • Specify therapeutic objectives • Select appropriate drug therapy: P-drug & STEPS approach (Safety, Tolerability, Effectiveness, Price, Simplicity) • Initiate therapy with appropriate details • Give information, instructions & warnings • Evaluate therapy regularly (e.g. Monitor treatment results)
- 34. NURSES’ ROLE • Education & proper training important in reducing medication related errors • Most errors do not reach patient because of barrier role played by a nurse • Independent calculations of paediatric doses by more than one person • Should be aware of correct storage requirements for drugs • Development of standardized dose & rate charts for products such as vasoactive drugs
- 35. REFERENCES • Medication Errors: Causes & its prevention, Singh I, Shafiq N, Malhotra S;Drugs Bulletin Vol.XXXVI No. 2, April 2011 • British journal of clinical pharmacology;67:6, 2009 • Look alike & Sound alike drug brand names; Mukundraj S Keny, PV Rataboli; Indian journal of clinical practice, Vol. 23, no.9, February 2013
- 36. REFERENCES