Medication Errors
Medication Errors
Medication errors, broadly defined as any error in
the prescribing, dispensing, or administration
of a drug, irrespective of whether such errors lead
to adverse consequences or not, are the single
most preventable cause of patient harm
Sources of Medication
Errors
Inaccurate recording and transcribing orders.
Unclear labeling of drugs
Misidentification of client
Incomplete delivery of drugs
Use of inadequate knowledge or inaccurate
knowledge base.
Time and performance pressure
Definitions
side-effect: a known effect, other than that
primarily intended, relating to the
pharmacological properties of a medication
adverse reaction: unexpected harm arising from
a justified action where the correct process was
followed for the context in which the event
occurred
e.g. an unexpected allergic reaction in a patient
taking a medication for the first time
error: failure to carry out a planned action as
intended or application of an incorrect plan
adverse event: an incident that results in harm
to a patient
Medication Error
an adverse drug event:
may be preventable (usually the result of an error) or
not preventable (usually the result of an adverse
drug reaction or side-effect)
a medication error may result in …
an adverse event if a patient is harmed
a near miss if a patient is nearly harmed or
neither harm nor potential for harm
medication errors are preventable
How Can Prescribing Go
Wrong
inadequate knowledge about drug indications and
contraindications
not considering individual patient factors such as
allergies, pregnancy, co-morbidities, other
medications
wrong patient, wrong dose, wrong time, wrong drug,
wrong route
inadequate communication (written, verbal)
documentation - illegible, incomplete, ambiguous
mathematical error when calculating dosage
incorrect data entry when using computerized
prescribing e.g. duplication, omission, wrong number
How can administration
go wrong
wrong patient
wrong route
wrong time
wrong dose
wrong drug
omission, failure to administer
inadequate documentation
Which patients are most
at risk
patients on multiple medications
patients with another condition, e.g. renal
impairment, pregnancy
patients who cannot communicate well
patients who have more than one doctor
patients who do not take an active role in their
own medication use
children and babies (dose calculations required)
In what situations
inexperience
rushing
doing two things at once
interruptions
fatigue, boredom, being on “automatic pilot”
leading to failure to check and double-check
lack of checking and double checking habits
poor teamwork and/or communication between
colleagues
reluctance to use memory aids
Medication errors
CLASSIFICATION OF MEDICATION ERROR
The medication error may be classified in to
mistakes,
slips,
lapses.
Medication errors may also be classified according
to where they occur in the medication use cycle, i.e.
at the stage of
prescribing,
dispensing,
administration of a drug.
Medication Errors
CONTRIBUTING FACTORS INCLUDE:
Lack of knowledge of the prescribed drug, its
recommended dose, and of the patient details contribute
to prescribing errors.
Illegible handwriting.
Inaccurate medication history taking.
Confusion with the drug name.
Inappropriate use of decimal points. A zero should
Always precede a decimal point (e.g. 0·1). Use of a
trailing zero (e.g. 1·0).
Use of abbreviations (e.g. AZT has led to confusion
between zidovudine and azathioprine).
Use of verbal orders.
Risk Factors
Risk factors for prescribing errors
Work environment
Workload Communication within the team
Physical and mental well being
Lack of knowledge
Organizational factors such as inadequate
training
Low perceived importance of prescribing
An absence of self awareness of errors
Approaches for reducing
prescribing errors
• Electronic prescribing may help to reduce the
risk of prescribing errors resulting from illegible
handwriting
• Computerized physician order entry systems
eliminate the need for transcription of orders by
nursing staff
DISPENSING ERROR
DISPENSING ERROR • From the receipt of the
prescription in the pharmacy to the supply of a
dispensed medicine to the patient.
This occurs primarily with drugs that have a
similar name or appearance. • Example :lasix®
(frusemide) and losec® (omeprazole)
Other potential dispensing errors include
wrong dose,
wrong drug,
wrong patient
Approaches to reducing
dispensing errors
Ensuring a safe dispensing procedure.
Separating drugs with a similar name or
appearance.
Keeping interruptions in the medicine
administration procedure to a minimum and
maintaining the workload of the nurse at a safe
and manageable level.
Awareness of high risk drugs such as potassium
chloride and cytotoxic agents.
Introducing safe systematic procedures for
dispensing medicines in the pharmacy.
ADMINISTRATION ERRORS
Discrepancy occurs between the drug received by
the patient and the drug therapy intended by the
prescriber.
Errors of omission - the drug is not administered
Incorrect administration technique and the
administration of incorrect or expired
preparations.
Deliberate violation of guidelines
CAUSES OF ADMINISTRATION
ERRORS
Lack of perceived risk
Poor role models
Lack of available technology
Lack of knowledge of the preparation or
administration procedures
Complex design of equipment.
CONTRIBUTING FACTORS TO DRUG
ADMINISTRATION ERRORS
Failure to check the patient’s identity prior to
administration
Environmental factors such a noise,
interruptions ,poor lighting
Wrong calculation to determine the correct dose
APPROACHES TO REDUCE DRUG
ADMINISTRATION ERRORS
Checking the patient’s identity.
Ensuring that dosage calculations are checked
independently by another health care professional
before the drug is administered.
Ensuring that the prescription, drug, and patient
are in the same place in order that they may be
checked against one another.
Ensuring the medication is given at the correct
time.
Minimizing interruptions during drug rounds
Performance
Requirements
How to make medication use safer:
use generic names
tailor prescribing for each patient
learn and practise thorough medication history
taking
know the high-risk medications and take precautions
know the medications you prescribe well
communicate clearly
develop checking habits
encourage patients to be actively involved
report and learn from errors
STEPS TO BE TAKEN IN
PREVENTING MEDICATION ERROR
Be sure to read labels at least 3 times, before
during after administration of the drug.
Prepare the medicine in a well lighted room.
Check the expiry date of the drug before
administration.
Be aware about ambiguous orders or drug names
and numerical and Consult doctor if any doubt.
Be alert to usually large dosage or excessive
increase in dosage ordered.
When in doubt, check order with prescriber,
pharmacist, literature .
STEPS TO BE TAKEN IN
PREVENTING MEDICATION
ERROR
Double check all calculation, even simple calculation
Do not allow any other activity to interrupt your
administration of medication to a client.
Routinely refer to drug interaction charts or drug
reference source and commit common interactive
drugs to memory.
Do not use any non standard abbreviation and symbols,
question if any one use
Read the leaflet of the drug carefully when giving new
drug first time.
Do not make assumptions of illegible orders.
Do not accept incomplete orders and telephonic or
verbal orders.
STEPS TO BE TAKEN IN
PREVENTING MEDICATION ERROR
Double check with a client who has allergies about all new
drugs as they are added in treatment plan
Question a drug form used in unfamiliar way.
Document all medication as soon as they are given.
When you have made an error reflect on what went
wrong ,ask how you could have prevented the error
Evaluate the context for any medication error to determine if
nurses have the necessary resources for safe medication
administration.
When repeated medication error occurs within a work area,
identify and analyze the factors that may have caused the
errors and take corrective action.
Attend in-service program that focus on the drug you
commonly administer.
STEPS TO BE TAKEN IN
PREVENTING MEDICATION ERROR
Follow the rights of medication administration
Right patient
Right drug
Right dose
Right time
Right route
Right recording
Right assessment
Right education
Right evaluation
Types of Medical Errors
There are four broad types of medication errors
Knowledge-based errors (through lack of
knowledge)—for example, giving penicillin, without
having established whether the patient is allergic
Computerized prescribing systems, bar-coded
medication systems, and cross-checking by others (for
example, pharmacists and nurses) can help to
intercept such errors
Rule-based errors (using a bad rule or misapplying a
good rule)—for example, injecting diclofenac in wrong
route
Proper rules and education help to avoid these types
of error
Action-based errors (called slips)—for example,
picking up a bottle containing diazepam from the
pharmacy shelf when intending to take one
containing diltiazem.
These can be minimized by creating conditions in
which they are unlikely (for example, by avoiding
distractions, by cross-checking, by labelling
medicines clearly and by using identifiers, such as
bar-codes
Memory-based errors (called lapses)—for
example, giving penicillin, knowing the patient to
be allergic, but forgetting. These are hard to
avoid; they can be intercepted by computerized
prescribing systems and by cross-checking
Mistakes (knowledge- and rule-based errors), slips
(action-based errors) and lapses (memory-based
errors) have been called ‘active failures.
Prescribing faults and prescription errors
Errors in prescribing can be divided into irrational
prescribing, inappropriate prescribing, ineffective
prescribing, under prescribing and
overprescribing, and errors in writing the
prescription.
The inadequacy of the term ‘error’ to describe all
of these is obvious.
Failing to prescribe an anticoagulant for a patient
in whom it is indicated (under prescribing) or
prescribing one when it is not indicated
(overprescribing) are different types of error from
errors that are made when writing a prescription.
Therefore it is preferable to use the terms
‘prescribing faults’ and ‘prescription errors’
The term ‘prescribing errors’ ambiguously
encompasses both types.
Achieving balanced prescribing Nine questions
should be asked before writing a prescription
Indication: is there an indication for the drug?
Effectiveness: is the medication effective for the
condition?
Diseases: are there important co-morbidities that
could affect the response to the drug?
Other similar drugs: is the patient already taking
another drug with the same action?
Interactions are there clinically important drug–
drug interactions with other drugs that the patient
is taking?
Dosage: what is the correct dosage regimen
(dose, frequency, route, formulation)?
Orders: what are the correct directions for giving
the drug and are they practical?
Period: what is the appropriate duration of
therapy?
Economics: is the drug cost-effective
ACTION TO BE TAKEN WHEN
ERROR OCCURS
The client safety becomes the top priority
The nurse assesses and examines the client’s
condition and notifies the physician of the incident
as soon as possible.
Once the client is stable the nurse reports the
incident to the appropriate person in the
institution like nursing supervisor or nursing
manager.
The nurse is also responsible for reporting the
incident. An incident report usually must be filed
within 24hours of an incident.
ACTION TO BE TAKEN WHEN
ERROR OCCURS
The report includes
client identifying information,
the location and time of the incident,
an accurate factual description of what occurred and what
was done,
the signature of the nurse involved.
The incident report is not a permanent part of the medical
record and should not be referred to in the record. This is to
legally protect the health care professional and institution.
The institution use incident report to track incident pattern
and to initiate quality, improvement programs as needed.
It is good risk management to report all medication error
including mistakes that do not cause obvious or immediate
harm or near misses.
Thank You
