STUDY ABSTRACT CORRECTED
- 1. A study regarding prevalence of MEDICATION ERROR & its causes ; To suggestbestpractices in MEDICATION SAFETY. ABSTARCT:- Introduction: Medication safety is an issue worldwide .It is estimated that more than half of all medicines over the world are prescribed, dispensed or sold inappropriately (WHO 2010). In high-income countries, this has been recognized a long time ago and a lot of efforts are dedicated to improve medication safety. If medications are not handled safely, it can lead to medication error. Medication error can increase the cost, prolong hospital stay and increase the risk of death almost two fold. Several studies have already demonstrated that clinical pharmacist can play major role in detection, prevention of medication errors and improvement of quality. Aim: Present study was aimed to detect and evaluate the incidence, types of medication errors and to rule out best practices for medication safety in AIMS FBD. Method: Prospective study was carried out from July 2014 to December 2014. Inpatients records of patients from various departments were reviewed during their stay in the hospital. Detected medication errors were documented and evaluated. Results:- A total of 1870 files were audited & 211 medication errors were seen. Maximum of medication error (54) were detected in the month of July 2014. And out of these were22 prescription errors, administration errors were 61, dispensing errors were 2; out of this 124 were documentation error. The causes of medication error were 88.2% were due to nurses, 10.40% were due to doctors and 0.98% errors were due to pharmacist. This study concluded that 11.28% medication errors were detected during study period and revealed that best practices of medication safety can play a major role in preventing these errors .
- 2. JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER Series1 54 31 34 25 39 28 0 10 20 30 40 50 60 NUMBEROFMEDICATIONERROR COMPILED DATA OF MEDICATION ERROR IN 2014 JULY AUGST SEPT OCT NOV DEC TOTAL %AGE FILES AUDITED 315 304 304 315 311 321 1870 MEDICATION ERROR 54 31 34 25 39 28 211 11.28342 PRESCRIPTION ERROR 4 3 3 5 4 3 22 10.42654 ADMINISTRATION ERROR 22 9 6 8 8 8 61 28.90995 DISPENSING ERROR 0 1 0 0 0 1 2 0.947867 DOCUMENTATIONERROR 28 18 24 12 26 16 124 58.76777 TRANSCRIPTION ERROR 0 0 1 0 1 0 2 0.947867
- 3. MEDICATION ERROR:- ACCORDING TO THE ROOT CAUSE ANALYSIS WE COULD FIND:- 10.42% 28.90% 0.94% 58.70% 0.94% MEDICATION ERROR PRESCRIPTION ERROR ADMINISTRATION ERROR DISPENSING ERROR DOCUMENTATION ERROR TRANSCRIPTION ERROR 88.62% 0.98% 10.40% PROFFESSIONALS INVOLVED IN MEDICATION ERRORS MEDICATION ERRORS BY NURSES MEDICATION ERRORS BY PHARMACIST MEDICATION ERRORS BY DOCTORS
- 4. ROOT CAUSE ANALYSIS SHOWED:- REASON FOR MEDICATION ERRORS BY NURSES:- Untrained Nurses. Increased Workload on Nurses Tran scripting the Wrong Indent Tran scripting the wrong Standard timing H.A.L.T. (Hunger, Anger, Late, Tired ) Environmental Issues : Dim Light, Noisy and disturbed Environment Documentation before administration of drugs OR Undocumented. REASON FOR MEDICATION ERRORS BY DOCTORS:- Illegible Handwriting Out of List Abbreviation used Drug Allergies not identified Irrational drug combination prescribed Non-compliance of Right drug, dose, route, frequency, Time REASON FOR MEDICATION ERRORS BY PHARMACY:- Misinterpretation of Prescription slip Confusion between LASA Drugs Increase number of IPD Patients results in Increase Work Load
- 5. FLOW DIAGRAM TO CLASSIFY THE INCIDENCE OF MEDICATION ERROR AND ADVERSE DRUG EVENTS (ADE) Incident Medication Error ADE with medication error Potential ADE MedicationError without potential harm ADE without medication error Severity Stage Responsible person Stage responsible person Severity Disability Preventability Stage Responsible Person Severe Disability INCIDENT FORM FILLED
- 6. Major Best Practices that can be suggested and are being followed is been listed through INPUT OUTPUT PROCESS:- INPUT PROCESS OUTPUT ANTIBIOTIC RECORDING POLICY Mentioning day 1,day 2,day3 MONITORING OF ANTIBIOTIC DOSE NARCOTIC POLICY Double Lock , Double Check , Double sign MONITORING OF NARCOTICS PATIENT SAFETY (HIGH ALERT POLICY) High alert storage, single lock, double check MONITORING OF HIGH ALERT MEDICATION VERBAL ORDER POLICY Verbal order stamp, Verbal order to be written within 24 hrs. MONITORING OF VERBAL ORDER & MEDICATION MEDICATION RECORDS Writing medication in capitals ,double check every day by in-charges LESS NO. OF MEDICATION ERRORS QUALITY INDICATORS Frequent auditing by the Quality team IMPROVING THE RECORDINGS PROPER MEDICATION LABELLING OF LASA DRUGS Labeling with date of opening & date of discard Keeping drugs separate REDUCE ERROR PROPER RCA RECORDING RCA with proper reasoning REDUCTION OF ERRORS
- 7. QUALITY AUDIT TRACKER Audits done by internal auditors (E –MODULE ) TRACKING OF ERRORS 10 RIGHTS OF MEDICATION Instead of 7 R’s started to follow 10 R’s REDUCTION OF MEDICATION ERROR ENGAGEMENT OF STAFF AND MEDICAL PROFESSIONALS IN QUALITY IMPROVEMENT Involving trained personnel (educators ,doctors) ( NABH INTERNAL AUDITOR”S COURSE ) NOTIFY NC’S RELATED TO EACH DEPT. MEDICATION EFFECTS Notifying medication effects of each drugs PREVENTION OF ADVERSE EFFECTS Use of SOCIALGROUP (WHATS APP) Involving nursing staff and quality team in one group. CIRCULATION OF ERRORS TO PREVENT THE ERRORS POST EVALUATION OF MEDICATION MANAGEMENT Competency assessment tool about medication management frequently EVALUATION ABOUT THE TRAINING POST EVALUATION OF DRUG CALCULATION Competency assessment tool about drug calculation frequently EVALUATION ABOUT THE TRAINING
- 8. CONCLUSIONS:- Medication errors are the serious problems in health care and can be the source of significant morbidly and mortality in the health care setting. In India, irrational use of drugs is common and this has led to antibiotic resistance, adverse drug reactions, medication errors and other drug related problems. Drug therapies are important parts of medical care, contributing to medication errors and other drug-related problems. Keeping up with the growing number of Prescription medications are a major challenge for the physicians & documentation of medication by hand is the major challenge for the nurses. Numerous studies have found that best practices of medication safety to prevent medication errors. However, achieving true change has been a challenge, and many hurdles still remain to be overcome.. A medication error is an episode associated with use of medication that should be preventable through effective control system. The factors that that increases the chance of medication errors are the attributes of complex mechanisms involved in the prescribing, dispensing and administration of drug. References:- 1. American society of hospital pharmacists. ASHP guidelines on preventing medication error in Hospital. Am J.Hosp.Pharm.1993; 50; 305-14. 2. Kohn LT, Corrigan GM, Donaldson MS. To err is human: building a safer health system. National Academy Press; Institute of medicine. Washington DC 1999. 3. Zed PJ. Drug-related visits to the emergency department. J Pharm Pract 2005; 18(5):329-35. 4. Hitchen L. Adverse drug reactions result in 250000 UK admissions a year. BMJ 2006; 332:1109. 5. Secretary Thompson announces steps to reduce Medication Errors, FDA Press Office Thursday, March 13, 2003. 6. Sujata sapkota, Nawin pudasaini, Chandan singh, Sagar GC. Drug prescribing pattern and prescription error in elderly: a retrospective study of inpatient record. Asian journal of pharmacy and clinical research 2011; 4( 3): 129 – 132 7. Sayali Pote, Pramil Tiwari, Sanjay D’cruz. Medication prescribing errors in a public, teaching hospital in India: A prospective study Pharmacy Practice 2007; 5(1): 17-20