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Chapter 6 Medication Safety * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Prescription-Filling Process Step 1 Prescribing errors ... – PowerPoint PPT presentation

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Title: medications

Chapter 6
Medication Safety
Learning Objectives
  • Understand the extent and effect of medical
    errors on patient health and safety
  • Describe how and to what degree medication errors
    contribute to medical errors
  • List examples of medication errors commonly seen
    in practice settings
  • Apply a systematic evaluation of opportunities
    for medication error to a pharmacy practice model
  • Identify the common medication errorreporting
    systems available

Medical Errors
  • A medical error is any circumstance, action,
    inaction, or decision related to healthcare that
    contributes to an unintended health result
  • Most of what is known about medical errors comes
    from information collected in the hospital
  • hospital data make up only a part of a much
    larger picture
  • most healthcare is administered in the
    outpatient, office-based, or clinic setting
  • Medical errors are difficult to define
  • possible causative circumstances are infinite

Medical Errors
  • Medical-related lawsuits show the scope of
    medical errors in the United States
  • One large government studied only medical errors
    during hospitalization
  • 44,000 to 98,000 people in the U.S. die each year
    as a result of medical errors (greater than the
    risk of death from accident, diabetes, homicide,
    or human HIV and AIDS)
  • multiple sources for potential medical errors

What are some examples of medical errors?
Edited by Dr. Ryan Lambert-Bellacov
What are some examples of medical
errors? Answer Lab tests drawn at the wrong
time (inaccurate results), major surgical errors
ending in injury or death
Medication Errors
  • A medication error is a medical error in which
    the source of error or harm includes a medication
  • Like medical errors
  • medication errors have no specific definition
    because the possible causes can be endless
  • information on the effect of medication errors
    comes mostly from studies done in the hospital
  • Medication-related deaths are estimated at about
    7,000 each year

Medication Errors
  • Fewer studies of medication errors in community
    practice exist
  • an estimated 1.7 of all prescriptions dispensed
    in a community practice setting contain a
    medication error (4 of every 250
  • Not all medication errors result in harm to a
  • 65 of the medication errors detected had a
    meaningful effect on the patients health

Medication Errors
  • Measuring results of medication errors
  • lost lives
  • disabled patients
  • time lost from work or school
  • cost to the healthcare system

billions of dollars physician visits
additional hospitalizations emergency room visits
admissions to long-term care continuation of disease
Healthcare Professionals Responsibility
  • Working in healthcare means making a commitment
    to first do no harm
  • The profession of pharmacy exists to safeguard
    the health of the public
  • Healthcare must focus on treating the patient
  • to the best possible outcome
  • by the safest possible means
  • No acceptable level of medication error exists
  • effect of a potential medication error on the
    patient cannot be predicted
  • each step in fulfilling medication orders should
    be reviewed with a 100 error-free goal

Healthcare Professionals Responsibility
Safety Note
The only acceptable level of medication errors
is zero.
Edited by Dr. Ryan Lambert-Bellacov
Healthcare Professionals Responsibility
  • MAs can identify potential patient sources of
    medication error
  • careful listening and observation during a
    patient or medical staff interaction
  • notifying the pharmacist
  • MAs make a significant contribution to patient
  • constant surveillance for potential sources of
    medication error

Tips for Reducing Medication Errors
  • Always keep the prescription and the label
  • Know common look-alike and sound-alike drugs
  • Keep dangerous or high-alert medications in a
    separate storage area
  • Always question bad handwriting
  • Prescriptions/orders should be correctly spelled
    with drug name, strength, appropriate dosing,
    quantity or duration of therapy, dose form, and
  • Use the metric system

Tips for Reducing Medication Errors
  • Question uncommon abbreviations
  • Be aware of insulin mistakes
  • Keep the work area clean and uncluttered
  • Verify information
  • Labels should always be compared with the
    original prescription by at least two people

Healthcare Professionals Responsibility
Safety Note
If information is missing from a medication
order, never assume. Obtain the missing
information from the prescriber.
Edited by Dr. Ryan Lambert-Bellacov
Tips for Reducing Medication Errors MAs
  • Use the triple-check system
  • Regularly review work habits
  • Verify information with the patient or caregiver
  • Observe and listen
  • Keep your work area free of clutter

Edited by Dr. Ryan Lambert-Bellacov
Patient Response
  • Most patients have the intended therapeutic
    response expected from the medication
  • Unique physical and social circumstances make it
    impossible to predict which
  • medication errors may result in no substantial
  • may result in death

Physiological Causes of Medication Errors
  • Each patient has a unique response to medication
  • genetically unique
  • speed at which medications are removed from
    body varies
  • Even a problem caught and corrected before harm
    occurs is still considered a medication error

Social Causes of Medication Errors
  • Outpatients can contribute to medication errors
    through incorrect administration
  • Social causes of error include
  • failure to follow medication therapy instructions
    because of cost
  • noncompliance
  • failure to receive therapy
  • misunderstanding instructions (language barriers)

Edited by Dr. Ryan Lambert-Bellacov
Social Causes of Medication Errors
  • Patients can contribute to medication errors by
  • forgetting to take a dose or doses
  • taking too many doses
  • dosing at the wrong time
  • not getting a prescription filled or refilled in
    a timely manner
  • not following directions on dose administration
  • terminating the drug regimen too soon

Social Causes of Medication Errors
  • Social causes may result in an adverse drug
    reaction, or a toxic dose
  • Over 50 of patients on necessary long-term
    medication are no longer taking their medication
    after 1 year
  • All of these social circumstances would be
    considered medication errors

Categories of Medication Errors
  • Possible causes of a medication error are
  • Categorizing errors into types aids in
    identification and prevention of possible causes
  • Categories focus on grouping errors under a set
    of common definitions

Edited by Dr. Ryan Lambert-Bellacov
Categories of Medication Errors
  • omission error a prescribed dose is not given
  • wrong dose error a dose is either above or below
    the correct dose by more than 5
  • extra dose error a patient receives more doses
    than were prescribed by the physician
  • wrong dose form error dose form or formulation
    that is not the accepted interpretation of the
    physician order
  • wrong time error drug is given 30 minutes or
    more before or after it was prescribed

Categories of Medication Errors
  • Errors can be classified by what causes the
    failure of the desired result
  • Errors can be categorized within three basic
    definitions of failure
  • human failure
  • technical failure
  • organizational failure

Categories of Medication Errors
  • Human failure is a failure that occurs at an
    individual level
  • pulling a medication bottle from the shelf based
    on memory, without cross-referencing the bottle
    label with the medication order/prescription
  • errors made by the patient such as non-compliance
    to prescribed drug therapy
  • Technical failure is a failure resulting from
    location or equipment
  • incorrect reconstitution of a medication because
    of a malfunction of a sterile-water dispenser
  • failure to properly operate automated equipment

Root Cause Analysis of Medication Errors
  • Root cause analysis is a logical and systematic
    process used to help identify what, how, and why
    something happened to prevent reoccurrence
  • With basic principles of root cause analysis, any
    person can
  • examine his or her own work flow to determine the
    opportunities for potential error
  • determine what type of failure the potential
    error may be
  • create a list of specific potential causes

Root Cause Analysis of Medication Errors
  • Identifying specific potential causes allows a
    person to take specific actions to prevent the
    potential error
  • Actions taken improve the quality of work being
  • Common causes of medication error by handlers and
    preparers include
  • assumption error
  • selection error
  • capture error

Root Cause Analysis of Medication Errors
  • assumption error an essential piece of
    information cannot be verified and is guessed or
  • misreading an abbreviation on a prescription
  • selection error two or more options exist, and
    the wrong option is chosen
  • using a look-alike or sound-alike drug instead of
    prescribed drug
  • capture error focus on a task is diverted
    elsewhere and an error goes undetected
  • something captures the persons attention,
    preventing the person from detecting the error or
    causing an error to be made

Root Cause Analysis of Medication Errors
Safety Note
  • Maintaining focused attention when filling
    prescriptions is important to avoid errors.

Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process in Community and
Hospital Pharmacy Practice
  • Review for potential causes of medication error
    begins with outlining work tasks in a
    step-by-step manner
  • Each step in this process can be a
  • source of medication error
  • place where pharmacy personnel can correct a
    medication error

Prescription-Filling Process in Community and
Hospital Pharmacy Practice
Safety Note
Each person who participates in the filling
process has the opportunity to catch and correct
a medication error.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
Safety Note
Outdated prescriptions should not be filled.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
Safety Note
A prescribers signature is required for a
prescription to be considered valid.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process Step 1
  • Prescribing errors include
  • poor handwriting
  • using nonstandard abbreviations
  • confusing look-alike and sound-alike drug names
  • wrong drug
  • using as directed instructions

Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process Step 1
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
Safety Note
A leading zero should precede values less than
one, but a zero should not follow a decimal if
the value is a whole number. A tenfold error
occurs if the decimal point is not detected.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process Step 1
  • Opportunities for medication errors increase with
    the number of medications a patient takes
  • common with many older patients
  • Profile review for every prescription should
  • check for existing allergies and multiple drug
  • check for drug interactions or duplication of

Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
Safety Note
Check the patient profile for existing allergies
or possible drug interactions.
Edited by Dr. Ryan Lambert-Bellacov
Prescription-Filling Process
  • Retrieve Medication
  • Products can contribute to errors with
  • look-alike labels
  • similarities in brand or generic names
  • similar pill shapes or colors
  • Use NDC numbers, drug names, and other
    information to verify selection of the correct
  • use both the original prescription and the
    generated label when selecting a manufacturers
    drug product from the storage shelf
  • use NDC numbers as a cross-check

Prescription-Filling Process
  • Step 5 Fill or Compound Prescription
  • Calculation and substitution errors are sources
    of medication errors
  • write out the calculation and have a second
    person check the answer
  • Take care when reading labels and preparing
    compounded products

Medication Error Prevention
  • Preventing medication errors means
  • carefully examining potential points of failure
  • using available resources to verify information
    given or decisions made
  • Drug identification is the most common error in
    dispensing and administration

Medication Error Prevention
Safety Note
Incorrect drug identification is the most common
error in dispensing or administration.
Edited by Dr. Ryan Lambert-Bellacov
Medication Error Prevention
  • Many medication errors occur during prescribing
    and administration
  • Prescribers are responsible for ensuring the
    five Rs or five rights
  • the right drug
  • for the right patient
  • at the right strength
  • given by the right route
  • administered at the right time

Innovations to Promote Safety
  • The physical pharmacy work setting can have a
    major contribution to the overall safety of any
    work environment
  • Automate and bar code all fill procedures
  • Maintain a clean, organized, orderly work area
  • Provide adequate storage areas
  • Encourage prescribers to use common terminology
    and only safe abbreviations
  • Provide adequate computer applications and

Innovations to Promote Safety
  • Innovations can minimize possibility of errors
  • In community pharmacy, redesigned packaging helps
    patients take medication safely
  • Target ClearRx packaging helps patients manage
    their medications
  • colored rings help patients identify medications
    intended for each family member
  • clear, easy-to-read label for patient
    administration instructions and cautions
  • includes a pullout patient information card or

Learn more about the Target label design
Innovations to Promote Safety
  • In hospital pharmacy, integrated computerized
    filling systems allow institutions to
  • improve efficiency
  • redirect resources

Medication Error and Adverse Drug Reaction
Reporting Systems
  • The first step in prevention of medication errors
    is collection of information
  • Fear of punishment is a concern with errors
  • people may decide not to report an error at all
  • allows the same error to occur again and again
  • Anonymous (no-fault) reporting systems have been
  • focus on fixing the problem, not fixing the blame

State Boards of Pharmacy
  • More than 20 states have mandatory
    error-reporting systems
  • most state officials admit medical errors are
    still under-reported mostly because of fear of
  • Some states have worked to reduce the fear of
  • allow pharmacists to document errors and
    error-prone systems without worry of punishment
  • most boards of pharmacy will not punish
    pharmacists for errors

State Boards of Pharmacy
  • Pharmacy technicians are an integral part of the
    error identification, documentation, and
    prevention process
  • The final and most important piece of medication
    error reporting is informing the patient that a
    medication error has taken place
  • commonly the task of the pharmacist

State Boards
  • The circumstances leading to the error should be
    explained completely and honestly
  • Patients should understand
  • the nature of the error
  • what if any effects the error will have
  • how they can become actively involved in
    preventing errors in the future
  • People are more likely to forgive an honest error

Joint Commission on Accreditation for Healthcare
  • Organizations can create a centralized point
    through which all members may channel error
    information safely
  • The Sentinel Event Policy was created by the
    Joint Commission on Accreditation for Healthcare
    Organizations (JCAHO) in 1996
  • A sentinel event is an unexpected occurrence
    involving death or serious physical or
    psychologic injury

Joint Commission on Accreditation for Healthcare
  • When a sentinel event is reported, the
    organization is expected to
  • analyze the cause of the error (perform a root
    cause analysis)
  • take action to correct the cause
  • monitor the changes made
  • determine whether the cause of the error is
  • Accreditation of hospitals depends on
    demonstrating an effective active errorreporting

Learn more about the Joint Commission
International Center for Patient Safety