medications

1
Chapter 12
Medication Safety
2
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

3
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
  setting
• 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

4
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
  exist

5
Medical Errors

• Pharmacy technicians should
• be constantly on the lookout for possible
  sources of errors
• adopt patient safetyoriented work practices
• take steps to protect the safety of patients
• become an important barrier against an adverse
  patient outcome

6
Discussion
What are some examples of medical errors?
Edited by Dr. Ryan Lambert-Bellacov
7
Discussion
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
8
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
  setting
• Medication-related deaths are estimated at about
  7,000 each year

9
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
  prescriptions)
• Not all medication errors result in harm to a
  patient
• 65 of the medication errors detected had a
  meaningful effect on the patients health

Edited by Dr. Ryan Lambert-Bellacov, chiropractor
for Back in the Game in West Linn, OR
10
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
11
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

12
Healthcare Professionals Responsibility
Safety Note
The only acceptable level of medication errors
is zero.
Edited by Dr. Ryan Lambert-Bellacov
13
Healthcare Professionals Responsibility

• Pharmacists are responsible for the accuracy of
  the medication-filling process
• technicians can assist in ensuring safety
• Pharmacists and pharmacy technicians can work
  together to create a net of safety
• Proper packaging and instruction on medication
  use
• facilitates correct administration by a patient

14
Healthcare Professionals Responsibility

• Technicians can identify potential patient
  sources of medication error
• careful listening and observation during a
  patient or medical staff interaction
• notifying the pharmacist
• Technicians make a significant contribution to
  patient safety
• constant surveillance for potential sources of
  medication error

15
Tips for Reducing Medication Errors

• Always keep the prescription and the label
  together
• 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
  route
• Use the metric system

16
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

Edited by Dr. Ryan Lambert-Bellacov, chiropractor
for Back in the Game in West Linn, OR
17
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
18
Tips for Reducing Medication Errors Pharmacists

• Check prescriptions in a timely manner
• Initial all checked prescriptions
• Visually check the product in the bottle
• Cross-reference prescription information with
  other validating sources
• Encourage documentation of all medication use
• Document all clarifications on orders
• Maintain open lines of communication with
  patients, healthcare providers, and caregivers

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Tips for Reducing Medication Errors Technicians

• 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
20
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
  harm
• may result in death

21
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

22
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
23
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

24
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

25
Categories of Medication Errors

• Possible causes of a medication error are
  numerous
• 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
26
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

27
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

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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

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Categories of Medication Errors

• Organizational failure is a failure because of
  organizational rules, policies, or procedures
• a policy or rule requiring preparing drugs in an
  inappropriate setting

Visit the Veterans Administration (VA) National
Center for Patient Safety Web site for a glossary
of patient safety terms
30
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

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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
  done
• Common causes of medication error by handlers and
  preparers include
• assumption error
• selection error
• capture error

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Root Cause Analysis of Medication Errors

• assumption error an essential piece of
  information cannot be verified and is guessed or
  presumed
• 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

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Root Cause Analysis of Medication Errors

• To prevent capture errors
• determine when and where in the
  prescription-filling process it is safe to allow
  focus on a task to be diverted
• Knowing when and when not to allow interruptions
  is important in individual safety practices

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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
35
Discussion
What are some ways to reduce each category of
error?
36
Discussion
What are some ways to reduce each category of
error? Answer Assumption errors may be avoided
by verifying all information instead of guessing
capture errors may be avoided by reviewing work
habits and determining when interruptions are or
are not appropriate selection errors may be
avoided by cross-referencing products chosen with
the order/prescription and the shelf label.
37
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

38
Prescription-Filling Process in Community and
Hospital Pharmacy Practice

• In the hospital setting medications pass through
  an extra set of handsthe nursesbefore reaching
  the patient
• an extra opportunity to prevent medication errors
• an additional source of potential medication
  errors
• Each step should be reviewed to determine what
  information is necessary to complete the step
• what resources can be used to verify the
  information
• what errors might result if information is missed
  or verification is not performed

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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
40
Prescription-Filling Process

• Think of each step in three parts
• information that must be obtained or checked
• resources that can be used to verify information
• potential medication errors that would result
  from a failure to obtain or check the necessary
  information using the appropriate resources

41
Prescription-Filling Process

• Step 1 Receive Prescription and Review Patient
  Profile
• Initial check of all key pieces of information is
  vital
• thoughtful and thorough initial review reduces
  the chances that an unidentified error will
  continue through the filling process
• Legibility Can you read and understand it?
• any unclear information should be clarified
  before any further action is taken

42
Prescription-Filling Process
Safety Note
Careful review of the prescription or order is
very important.
Edited by Dr. Ryan Lambert-Bellacov
43
Prescription-Filling Process Step 1

• Validity Is the prescription valid?
• requirements may vary from state to state
• every technician should be familiar with the
  definition of valid prescription for the state in
  which he or she practice
• does it contain all the required information to
  be valid?
• a prescription is valid for up to 1 year (less in
  some cases) from the date of its writing
• if not valid, the prescription should not be
  filled

44
Prescription-Filling Process
Safety Note
Outdated prescriptions should not be filled.
Edited by Dr. Ryan Lambert-Bellacov
45
Prescription-Filling ProcessStep 1

• Patient information Is there enough detail to
  ensure that unique individuals can be pinpointed?
  
• full names, addresses, dates of birth, and phone
  numbers give multiple points to cross-reference
  and separates patients
• date of birth and allergies should always be
  included
• Physician information Is it sufficient to
  determine that a licensed prescriber wrote the
  prescription?
• contact information should be included
• no prescription or medication order is valid
  without the signature of the prescriber

46
Prescription-Filling Process
Safety Note
A prescribers signature is required for a
prescription to be considered valid.
Edited by Dr. Ryan Lambert-Bellacov
47
Prescription-Filling ProcessStep 1

• Medication information should include

drug name route of administration
strength refills or length of therapy
dose directions for use
dose form dosing schedule
Edited by Dr. Ryan Lambert-Bellacov
48
Prescription-Filling ProcessStep 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
49
Prescription-Filling ProcessStep 1
Edited by Dr. Ryan Lambert-Bellacov
50
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
51
Prescription-Filling ProcessStep 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
  include
• check for existing allergies and multiple drug
  therapy
• check for drug interactions or duplication of
  therapy

Edited by Dr. Ryan Lambert-Bellacov
52
Prescription-Filling Process
Safety Note
Check the patient profile for existing allergies
or possible drug interactions.
Edited by Dr. Ryan Lambert-Bellacov
53
Prescription-Filling Process

• Step 2 Enter Prescription into Computer
• Accuracy in this function can make the difference
  between
• a patient receiving a correct and appropriate
  medication
• or
• a prescription that could cause the patient
  serious harm or death

Edited by Dr. Ryan Lambert-Bellacov
54
Prescription-Filling ProcessStep 2

• Concentration and focus are very important
• prescription information should be compared with
  choices from the computer menu
• Does the form or formulation match the route of
  administration?
• Compare each data element of the completed entry
  with the same data elements on the original
  prescription

Check the Institute for Safe Medication Practices
Web site for dangerous abbreviations or dose
designations
55
Prescription-Filling Process
Safety Note
Prescriptions that contain unapproved
error-causing abbreviations should be confirmed
with the prescriber.
Edited by Dr. Ryan Lambert-Bellacov
56
Prescription-Filling Process
Safety Note
Confirm that information entered into the
computer matches the original prescription.
Edited by Dr. Ryan Lambert-Bellacov
57
Prescription-Filling Process

• Step 3 Generate Prescription Label
• Check for the accuracy of any technology in the
  prescription filling process
• Cross-check the label output from the computer
  with the original prescription
• make sure that a typing error or inherent program
  malfunction did not alter the information
• Is the correct patient name on the label?
• Are the drug, dose, concentration, and route
  information identical to the original
  prescription?

58
Prescription-Filling Process

• Step 4 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
  product
• 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

59
Prescription-Filling ProcessStep 4

• Accidental substitution of one drug or ingredient
  for another is one of the most serious events
  that can occur in pharmacy practice
• Most pharmacy practices possess a computer-based
  pill identification program and use a shelf
  labeling system to organize inventory
• visual comparison of the medication dispensed
  with a picture of the medication

Edited by Dr. Ryan Lambert-Bellacov
60
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

61
Prescription-Filling ProcessStep 5

• Medication errors may occur when
• using more than one container of product
• preparing more than one product at a time
• distractions and interruptions intrude
• All equipment should be maintained, cleaned, and
  calibrated on a regular basis
• potential for serious harm to a patient if the
  residue or dust from an allergy-causing
  medication contaminates the patients
  prescription
• cleaning the counting tray with alcohol after
  each drug is dispensed is recommended

62
Prescription-Filling Process
Safety Note
When compounding, do not allow interruptions and
prepare products one at a time.
Edited by Dr. Ryan Lambert-Bellacov
63
Prescription-Filling ProcessStep 5

• Caution and warning labels on a prescription
  container serve as reminders to patients about
  drug handling or administration
• Computerized systems generate caution and warning
  labels with the prescription label
• coordinate with patient information handouts
• should be included with prescription labeling

64
Prescription-Filling Process

• Step 6 Review and Approve Prescription
• The pharmacist must be the one to review and
  approve the prescription
• verifies the quality and integrity of the end
  product
• Providing the pharmacist with all resources that
  are useful to ensure accurate verification is
  vital to patient safety

65
Prescription-Filling ProcessStep 6

• Determine what information and resources are
  important
• ask whether the information provided with the
  medication filled allows the pharmacist to
  retrace the technicians steps in filling the
  prescription
• Can the pharmacist determine whether prescription
  is valid, patient information is accurate, and
  medication correctly prepared from information
  provided with the finished product?

66
Prescription-Filling Process
Safety Note
The pharmacist must always check the technicians
work.
Edited by Dr. Ryan Lambert-Bellacov
67
Prescription-Filling Process

• Step 7 Store Completed Prescription
• Ensuring the integrity of medication is an
  important part of medication safety
• Many medications are sensitive to light,
  humidity, or temperature
• failure to properly store medications may result
  in loss of drug potency or effect
• improper storage of a drug may result in a
  degraded product that causes serious harm
• Well-organized and clearly labeled storage
  systems help to keep a patients medications
  together and separate from other patients

68
Prescription-Filling Process

• Step 8 Deliver Medication to Patient
• In community pharmacies, medication is directly
  received by the patient
• In hospitals, medications are administered and
  monitored by someone other than the patient
• Verify prescription information against knowledge
  and expectations of patient or caregiver
• Comparing completed prescription against
  information provided by patient allows a final
  opportunity to capture potential errors

69
Prescription-Filling Process
Safety Note
Pharmacy technicians cannot instruct patients. If
a technician suspects that a patient requires
instruction, then the technician should alert the
pharmacist.
70
Prescription-Filling ProcessStep 8

• In hospitals, medication is ultimately received
  by the nurse
• an additional person to confirm accuracy and
  appropriateness
• creates opportunity for a medication error
• Notify the nurse that a newly prescribed
  medication has been delivered to the floor

71
Prescription-Filling ProcessStep 8

• Ask whether
• the nurse knows about the medication
• medications delivered were all they were
  expecting
• If a drug is missing from the drug therapy
  combination, treatment is incomplete
• incomplete therapy is also a medication error

72
Discussion
What information should be checked at each step
of the prescription fill process?
73
Discussion
What information should be checked at each step
of the prescription fill process? Answer
Patient identity, medication dose and form,
directions for use
74
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

75
Medication Error Prevention

• Pharmacy technicians own a substantial portion
  of the prescription-filling process
• first to examine a prescription submitted for
  filling
• last to handle medication before it reaches the
  patient
• Pharmacy technicians have the most opportunities
  to prevent medication errors
• can identify potential sources of error beyond
  prescription dispensing
• interact with a patient or nurse when a
  prescription comes in or goes out of the pharmacy

76
Medication Error Prevention
Safety Note
Incorrect drug identification is the most common
error in dispensing or administration.
Edited by Dr. Ryan Lambert-Bellacov
77
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

78
Medication Error Prevention

• Pharmacy practice overlays physician
  responsibility and thereby facilitates patient
  safety and error prevention by processes to
  verify the following
• the correct patient is being given the
  medications
• other associated medications are correct
• correct drug is dispensed
• correct dose is prepared
• correct route of administration is indicated
• appropriate dose form is prepared
• correct administration times
• correct conditions for administration are met

79
Patient Education

• Patients and caregivers must have necessary
  knowledge to administer, handle, and support safe
  medication use
• Pharmacy technicians can encourage patients to
• ask questions
• relay complete medical and allergy history
• check medications for information on
  administration
• Pharmacy technicians should be actively involved
  in monitoring for potential errors

80
Patient Education

• Pharmacy technicians cannot instruct patients but
  can
• encourage patients to become informed about their
  conditions
• encourage patients to ask the pharmacist
  questions about prescribed medications
• assist patients in becoming more informed
• empower them to be advocates for their own safety
  and health

81
Patient Education

• Patients should understand ten key pieces of
  information about every medication
• what the brand and generic names are
• what the medication looks like
• why they are taking the medication, and how long
  they will have to take it
• how much to take, how often, and the best time or
  circumstances to take a medication
• what to do if they miss a dose

Edited by Dr. Ryan Lambert-Bellacov
82
Patient Education

• medications or foods which interact with what
  they are taking
• whether new medication is in addition to or
  replaces medication currently taken
• common side effects and what to do about them
• special precautions for each particular drug
  therapy
• where and how to store the medication

83
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
  hardware

84
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
  printout

Learn more about the Target label design
85
Innovations to Promote Safety

• In hospital pharmacy, integrated computerized
  filling systems allow institutions to
• improve efficiency
• redirect resources

86
Innovations to Promote Safety

• When a pharmacist is actively involved in
  medication decisions, safety and outcomes for
  patients are substantially improved
• technologic advances empower the pharmacy
  technician staff to become more productive, and
  as a result, pharmacists are freed to become more
  involved in patient care

Learn more about McKessons technologies
87
Discussion
What can a pharmacy technician do to prevent
medication errors?
88
Discussion
What can a pharmacy technician do to prevent
medication errors? Answer A pharmacy technician
is in the ideal position to identify potential
sources of error, encourage patient education,
and monitor for problems.
89
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
  established
• focus on fixing the problem, not fixing the blame

90
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
  punishment
• Some states have worked to reduce the fear of
  reporting
• allow pharmacists to document errors and
  error-prone systems without worry of punishment
• most boards of pharmacy will not punish
  pharmacists for errors

91
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

92
State Boards of Pharmacy

• 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

93
Joint Commission on Accreditation for Healthcare
Organizations

• 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

94
Joint Commission on Accreditation for Healthcare
Organizations

• 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
  eliminated
• Accreditation of hospitals depends on
  demonstrating an effective active errorreporting
  system

Learn more about the Joint Commission
International Center for Patient Safety
95
United States Pharmacopeia

• The United States Pharmacopeia (USP) supports two
  types of reporting systems for the collection of
  medical errors and adverse drug reactions
• Medication Errors Reporting Program
• MEDMARX

Edited by Dr. Ryan Lambert-Bellacov
96
United States Pharmacopeia

• The Medication Errors Reporting Program is
  designed to allow healthcare professionals to
  report medication errors directly
• MEDMARX is an internet-based program for use by
  hospitals and healthcare systems for documenting,
  tracking, and trending medication errors

97
United States Pharmacopeia

• Both USP programs support research into
  medication-related adverse events
• use the information to develop medication-specific
  patient safety initiatives

Learn about the Medication Errors Reporting
Program and MEDMARX
98
Food and Drug Administration

• Food and Drug Administration (FDA) is the
  government body responsible for approving the
  safety of medications and medical devices
• MedWatch is an FDA reporting system for adverse
  events resulting from medications and medical
  devices

99
Food and Drug Administration

• FDA uses MedWatch information to track
  unrecognized problems or issues not apparent when
  the medication or medical device was approved
• A problem or potential for error does not mean
  the product will be removed from the market
• often safety risks may be reduced or eliminated
  by
• improving of prescribing information
• education of healthcare professionals or the
  public
• name change

100
Food and Drug Administration

• The FDA provides an adverse event reporting form

Get an adverse event reporting form
101
Institute for Safe Medication Practices

• The Institute for Safe Medication Practices
  (ISMP)
• non-profit healthcare agency
• comprised of physicians, pharmacists, and nurses
• The mission statement is
• to understand the causes of medication errors
  and to provide time-critical error reduction
  strategies to the healthcare community, policy
  makers, and the public
• ISMP in concert with USP provides a confidential
  national voluntary program
• MERP (Medication Errors Reporting Program)

Visit ISMP
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Institute for Safe Medication Practices

• Errors reported through MERP include
• wrong drug, strength, or dose
• confusion over look-alike and sound-alike drugs
• incorrect route of drug administration
• calculation or preparation errors
• misuse of medical equipment
• errors in prescribing, transcribing, dispensing,
  or monitoring medications
• Reports can be completed on-line

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Institute for Safe Medication Practices

• ISMP has
• sponsored national forums on medication errors
• recommended addition of labeling or special
  hazard warnings on potentially toxic drugs
• encouraged revisions in potentially dangerous
  pharmaceutical advertising
• promoted the use of a zero prior to a decimal
  number less than 1 on drug doses

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Institute for Safe Medication Practices

• ISMP is active in disseminating information to
  healthcare professionals and consumers
• email newsletter
• journal articles
• videotape training exercises
• ISMP web site posts
• FDA Safety alerts
• ISMP Hazard Alerts

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Discussion
Why is the most effective error-reporting
systems, anonymous or no-fault?
106
Discussion
Why is the most effective error-reporting
systems, anonymous or no-fault? Answer Fear of
punishment may be a deterrent to
error-reporting.
107
Discussion
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