MEDICATION ERRORS.pptx
- 1. MEDICATION ERRORS & ADVERSE DRUG EVENTS
- 3. OBJECTIVES To understand the basics about the Medication Errors, Adverse Drug Events, Adverse drug reactions and State what percentage of adverse medical events are caused by medications List out the causes of Medication Errors, Adverse Drug Events, Adverse drug reactions List and define the types of medication errors Distinguish between medication errors, adverse drug events and potential adverse drug events List the most common systems failures that cause adverse drug events To report and analyze the Medication Errors, Adverse Drug Events, Adverse drug reactions
- 5. What is an adverse drug event (ADE)? • An adverse drug event is “an injury resulting from the use of a drug. Under this definition, the term ADE includes harm caused by the drug (adverse drug reactions and overdoses) and harm from the use of the drug (including dose reductions and discontinuations of drug therapy).”1 Adverse Drug Events may results from medication errors but most do not. What is an adverse drug reaction (ADR)? • An adverse drug reaction is a “response to a drug which is noxious and unintended and which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for the modification of physiologic function.” Note that there is a causal link between a drug and an adverse drug reaction. In sum, an adverse drug reaction is harm directly caused by the drug at normal doses, during normal use.
- 6. • How does an ADR differ from a side effect or allergy? • An allergy is an adverse drug reaction mediated by an immune response (e.g., rash, hives). A side effect is an expected and known effect of a drug that is not the intended therapeutic outcome. The term “side effect” tends to norminalize the concept of injury from drugs. • It has been recommended that this term should generally be avoided in favor of adverse drug reaction.
- 9. • Safety: Freedom from accidental injuries. • Error: The failure of a planned action to be completed as intended (i.e. error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning).Errors may be errors of commission or omission, and usually reflect deficiencies in the systems of care. • Adverse event: An injury related to medical management, in contrast to complications of disease. Medical management includes all aspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Adverse events may be preventable or non-preventable. • Preventable adverse event: An adverse event caused by an error or other type of systems or equipment failure. • “Near-miss” or “close call”: Serious error or mishap that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted. Also called potential adverse event.
- 10. • A Medication Error is an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication. • An Adverse Drug Event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication. • Event: Any deviation from usual medical care that causes an injury to the patient or poses a risk of harm. Includes errors, preventable adverse events, and hazards (see also incident). • Incident (or adverse incident): Any deviation from usual medical care that causes an injury to the patient or poses a risk of harm. Includes errors, preventable adverse events, and hazards. • Potential adverse event: A serious error or mishap that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted (also called “near miss” or “close call”). • Latent error (or latent failure): A defect in the design, organization, training or maintenance in a system that leads to operator errors and whose effects are typically delayed.
- 11. MEDICATION ERROR • “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 labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use” • Errors are usually unintentional and preventable.
- 12. TYPES OF MEDICATION ERRORS • Prescribing errors • Omission errors • Improper dose errors • Unauthorized drug errors • Deteriorated drug errors • Wrong time errors • Wrong dosage form errors • Wrong drug preparation errors • Wrong administration technique errors • Monitoring errors • Compliance errors
- 13. FACTORS THAT MAY 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
- 14. 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 Factors associated with tasks • Repetitive systems for ordering, processing and authorization • Patient monitoring (dependent on practice, patient, other health care settings, prescriber)
- 15. 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) Factors associated with medicines • Naming of medicines • Labelling and packaging
- 16. 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 Primary-secondary care interface Limited quality of communication with secondary care Little justification of secondary care recommendations
- 17. REPORTING OF MEDICATION ERRORS
- 19. Why should I report? • Medication errors are an important preventable cause of morbidity and mortality. If errors are reported, • corrective measures can be undertaken to prevent them. This will improve the safety of the patients. MOREOVER, MEDICATION ERROR REPORTING IS BLAME FREE. Are there issues concerning the confidentiality of the patient / person committing error? • There are absolutely no issues regarding confidentiality as the identifier information (like name, hospital • number) of either the patient or the person committing the error need not be reported. The details of the • reporter are optional and when furnished, will be kept confidential. What to report? • All medication errors should be reported. Even potential errors (events that have potential to cause error) can • be reported. A few examples of medication errors are given above. Please do remember that there is no blame and you can report any medication error committed by anyone.
- 20. Who can report? • Any health care professional (doctors, nurses, pharmacists and allied health care professionals) can report • medication errors. When to report? • Whenever you come across a medication error, committed by self or anyone, you can report. There is no strict • timeline within which it should be reported. But it is advisable to report immediately. How to report?
- 21. Potential solutions • A number of studies have explored ways to improve the quality of prescribing in primary care. However, outcomes are heterogeneous and few studies have specifically focused on medication errors. Reducing medication errors and improving medication safety requires a systems approach. • Strategies employed include using health care professionals, computer technology and educational programmes, often within multifaceted interventions. There is also an emphasis on the elderly population. Some interventions have targeted specific clinical areas, such as infectious diseases and appropriate antibiotic use.
- 22. Potential solutions • Medication reviews and reconciliation • Automated information systems • Education • Multicomponent interventions
- 23. Medication reviews and reconciliation • Medication review is a process of patients` medicines evaluation in order to improve the health outcomes and mitigate the drug- related problems. A systematic review of 38 studies of primary care interventions designed to reduce medication related adverse events found that most successful interventions included a medication review conducted by a pharmacist or other clinicians, or focused on multicomponent interventions, which had a medication review by a primary care professional as one component. • Medication reconciliation is the formal process of establishing and documenting a consistent, definitive list of medicines across transitions of care and then rectifying any discrepancies. Increased medication discrepancies at discharge are associated with an increased number of prescribed medications, underscoring the need to address polypharmacy as a multifaceted threat to patient health. • The accuracy of medication information on discharge summaries is generally poor
- 24. Automated information systems • A review of 10 randomized trials of computerized interventions found a reduction in medication errors in half of the studies. Computerized provider order entry (CPOE) with decision support may be effective if targeted at a limited number of potentially inappropriate medications and is designed to reduce the alert burden by focusing on clinically-relevant warnings.There is substantial evidence which supports the use of CPOE to decrease the frequency of medication errors in the in-patient setting. • One study found that the likelihood of error occurrence was decreased by 48% when an order was processed via CPOE. However, there is additional research needed to link a decrease in medication errors to a decrease in patient harm.
- 25. Education • As outlined in another monograph in this Technical Series, educating health care providers is a key element to improve safety in primary care. This holds true in reducing medication errors where education is often part of multicomponent interventions
- 26. Multicomponent interventions • Many studies include more than one intervention. Evidence supports the use of multifaceted approaches for improving medication practices. In a review of 10 studies on improving the appropriateness of polypharmacy in the elderly, nine studies involved complex interventions (the remaining one employed computer decision support). Overall, there were reductions in inappropriate prescribing and the number of adverse drug events
- 27. What Can Health Care Professionals Do to Improve Medication Use Safety? • Traditional methods • Unit dose drug distribution systems: • Intravenous mixture systems: • Practices for safe medication use system • Clinical Pharmacy Programmes
- 28. Intravenous admixture systems: • IV push (nurses prepare and administer the dose directly using a syringe) • Volume control chambers (a container between an IV solution and the IV tubing into which medicines can be added for infusion) • Pharmacy prepared minibags/glass bottles (medicines are added to a small volume of IV fluid under sterile conditions in the pharmacy) • Spring-loaded syringe-based system (a device that uses a spring to put pressure on the plunger of a syringe to facilitate delivery of a dose) • Point-of-care activated system (a plastic bag containing IV fluid and a special port for directly attaching a vial of medicine for mixing at the bedside) • Outsourced piggyback systems (a central pharmacy prepares IV containers containing medicines and delivers these to the hospital for use) • Manufacturer’s container (a glass vial that allows for reconstitution of the dose and direct administration to the patient from the vial using an IV set) • Premixed and frozen minibags (pre- made IV solutions containing the medicines, some of which are frozen because of limited stability)
- 29. Practices for safe medication use system include: • Formulary management and medication use policy • Implement standardised infusion concentrations based on local and national practices that are appropriate for most practice settings • Establish comprehensive IV medication administration policies with standardised administration times, upper and lower dosage limits, and administration rates • Prescribing and ordering • Use standardised orders (paper or electronic) for IV medicines • Prescribe standardized infusion diluents, concentrations and units (preferably commercially available products) • Storage • Differentiate look-alike medicines, including separate storage locations (LASA)
- 30. • Prohibit or impose tight security precautions on stocking concentrated injectable products and more than one concentration of an IV medicine on patient care units • Preparation and dispensing • Dispense IV medicines in a ready-to- administer form that does not require manipulation before administration to the patient • Standardise the process for compounding sterile preparations, with procedures to minimise unnecessary interruptions and distractions, trace and verify the accuracy of compounding, and provide for pharmacist checking of accuracy administering • Require independent double-checks and documentation of administration of selected high-alert medicines • Monitoring medication use • Have antidotes, supportive medicines, dosing and administration information and resuscitation equipment immediately available in patient care areas • Establish standard operating procedures for communication
- 31. THANK YOU