how to minimize medication error
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In the name of Allah, Most Gracious, Most
Merciful.
STRATEGIC PLAN TO MINIMIZE
MEDICATION ERRORBy
Mr.Jawed Ali Quazi
OUR GOALS FOR TODAY
Define medication errors and classify their significance
Understand the extent of medication errors and their impact on patient care
Discuss the many factors that contribute to errors and the impulse to “place blame” on healthcare workers
Examine approaches to minimize the risk of medication errors
DEFINING MEDICATION ERRORS
"A medication error is 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:
National Coordinating Committee-Medication Error Reporting and Prevention (NCC MERP); accessed at http://www.nccmerp.org/aboutMedErrors.html; Jan. 2012.
• professional practice• health care products• procedures and systems• product labeling, packaging, and nomenclature
• dispensing• distribution• administration• education• monitoring
Medication Errors in 1,116 Hospitals
Medication Error (Overall)
430,586
5.07% (of admission)
1 error every 22.7 hr
1 every 19.7 admission
found 616 medication errors (5.7%), 115 potential ADEs (1.1%), and 26
ADEs (0.24%). Of the 26 ADEs, 5 (19%) were preventable.
Most potential ADEs occurred at the stage of drug ordering (79%)
The rate of potential ADEs was significantly higher in neonates in the neonatal intensive care unit.
Ref: JAMA. 2001;285(16):2114-2120. doi:10.1001/jama.285.16.2114
Reviewed 10 778 medication orders
IF YOU SAW THIS, WOULD YOU FLY ?
Extra ExtraAirlines expect 1-2jets to crash daily
Over 1000 deaths expected weekly
BUY WHAT ABOUT BEING A PATIENT IN THE HEALTH CARE SYSTEM
Kohn et al. Committee on quality health care in America. IOM. Academy Press. 1999.
Extra ExtraAirlines expect 1-2 jets to
crash daily
Over 1000 deaths expected weekly
=44,000 – 98,000deaths annually
due tomedical errors
A Comparison of Risks
Risk (per flight) of dying in a commercial airline accident 1 in 8 million*
Risk (per hospital admission) of dying from a medical error >1 in
1,000
*1 in 2 million from 1967-1976
Accidents123,706
MedicalErrors
~100,000
Alzheimer's74,632
Diabetes71,382
www.cdc.gov/nchs/fastats. Accessed Jan 2012. Based on 2007 data.
How medical errors rank as cause of mortality
Heart616,067
Cancer562,875
Stroke135,952
Lung127,924
NCC MERP. accessed Jan 2012. www.nccmerp.org
Classifying medication errors
A circumstances exist for potential errors to occur
B an error occurred but did not reach the patient
C error reached the patient but did not cause harm
D patient monitoring required to determine lack of harm
E error caused temporary harm and some intervention
F temporary harm with initial or prolonged hospitalization
G error resulted in permanent patient harm
H error required intervention to sustain the patient’s life
I error contributed to the patient’s death
TYPES OF MEDICAL ERRORS
Surgical Errors 47.7%
Wound Infections,
13.6%
Surgical Failure, 3.6%
Mistakes during
Surgery, 12.9%
Mistakes discoveredLater, 10.6%
Others 7%
NON-SURGICAL ERRORS 52.3%
Medication Errors
19.4%
Diagnostic, 8.1%
Therapeutic, 7.5%
Procedure
Related, 7%
Others,10.3%
MEDICATIONERRORS (20%)
Ordering/ Prescribing
39%Administrati
on 38%
Dispensing 12%
Transcribing 11%
Some reasons errors occur
• poor communications within healthcare team• verbal orders
• poor handwriting• improper drug selection• missing medication• incorrect scheduling
• look alike / sound alike drugs
• polypharmacy
• availability of floor stock (no second check)• drug interactions
• hectic work environment• lack of computer decision support
CAUSES OF MEDICATION ERRORS Calculation errors Improper use of zeros & decimal points Inappropriate use of abbreviations Careless prescribing Illegible handwriting Missing information Drug product characteristics Compounding /drug preparation errors Prescription labeling Work environment & personnel issues Deficiencies in medication use systems
Medication Errors, Who Makes Them?
Physician
Pharmacist Nurse Patient
Any member of the health care team
MEDICATION ERROR REPORTS FOR LAST TWO YEARS
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
Month 10
Month 11
Month 12
0
100
200
300
400
500
600
700
432
509
432
599555
432
338
444
376400
326300
338
462449
397379
300288309314
282322335
1434
1435
QUARTERLY MEDICATION ERROR DEPT WISE
Medica
l
Surgic
alOrth
oCh
est
Cardi
ology EN
T
Ophtha
lmolo
gyPea
dia
Urolog
y
Dermato
logy
AKU
Emerg
ency
OBG/LR
Dental
Neurol
ogy
Psychi
atric c
linic
0
20
40
60
80
100
120
140
160
180
Series1
MEDICATION ERROR MOST COMMON TYPE
No Diagnosis Prohibited Abbr No Gen Name Prescription Previlage
No.file No. weak strenght 0
20406080
100120140160180
Series1
MOST COMMON ERROR TOTAL NO. OF ERROR QUARTERNo Diagnosis 148Prohibited Abbr 80No Gen Name
168Prescription Previlage 57No.file No. 98Weak Strength 57
PREGABALIN (LYRICA)An anticonvulsant approved in Canada and the US since2005 to treat neuropathic pain approved by the European Commission in 2006 to treat generalized anxiety disorder. The maximum dose of pregabalin depends on its indication but should not exceed 600 mg/day.
PREGABALIN (LYRICA)Clinical studies including 5500 patients showed that euphoric effects were reported more frequently in pregabalin groups versus placebo (4% vs. 1%, respectively).A clinical abuse liability study found that pregabalin had a potential for euphorigenic activity in susceptible populations.Therefore scheduled by the US Drug Enforcement Administration under the Controlled Substances Act as a Schedule V drug, indicating that it had abuse potential.
Emerg Med J 2013;30:874 doi:10.1136/emermed-2013-203113.20 •Abstracts
Lyrica Nights–recreational Pregabalin Abuse In An Urban Emergency DeptAuthor Affiliations1.Emergency Department, Royal Victoria Hospital, Belfast, United Kingdom
"Pregabalin Abuse, Dependence, and Withdrawal: A Case Report." The American Journal of Psychiatry, 167(7), p. 869
ROOT CAUSE ANALYSISNo Medical Reconciliation
Computer Operated Entry
Hospital File Number
Prescribing Privilege
MEDICAL RECONCILIATIONReconciliation: A process of identifying the most accurate list of all medications a patient is taking—including name, dosage, frequency, and route.Requires comparing the patient’s list of current medications against the physician’s admission, transfer, and/or discharge ordersNeeds even for OPD patients by MOH
http://www.ihi.org/NR/rdonlyres/598D427A-4BDA-419D-91B5-B836D23A6F1D/0/CampaignOverview101105.ppt#358,9,Prevent Adverse Drug Events by Implementing Medication Reconciliation
ZANTAC (Ranitidine 150mg)
ZINNAT (Cefuroxime 250mg tablet/ susp )
Generic NameDiagnosis
IMPACT ON PATIENT Factors:
health status of patientsmagnitude of overdosedamage as result of omission
Financial Implicationsprolong hospital stays & increase health
care expenses estimated to cost billions of dollars annually
additional medical management
Sources of Error• Prescribing error - selecting the wrong or
inappropriate drug/dose/formulation/duration etc• Communicating those instructions• Supply error - timely; wrong drug, dose, route;
expired medicines, labelling.• Administration error - timing; wrong route; wrong
rate/technique.• Lack of user education - actions to take.
MEDICATION ERRORPREVENTION
Prescribers
Avoid illegible Handwriting
Minimize Telephone & Verbal orders
Document Drug Allergies
Familiar With medication
Order system
Update drug knowledge
WRITE CLEARLY
MISTAKE IDENTITY
DANGEROUS ABBREVIATIONS “AZT” for zidovudine (Retrovir)
could be azathioprine (Imuran) “U” HAS been mistaken for “zero”(o)
10 U insulin order & patient received 100 insulin units
“QD” has been read as “QID” or “OD” DO NOT USE Lists
The Joint Commission Institute for Safe Medication Practices (ISMP
DECIMAL POINTS & ZEROS Decimal point errors cause significant
consequences Decimal point errors occur
result of miscalculationwhen writing orders or instructions result of artifact on faxed order
Always write leading zero in front of number < 1
Never write trailing zeros
SOLUTION: ENHANCE TECHNOLOGY INTERVENTIONS
e-Prescribing Systems: Reduced medication errors by 85% Net cost savings of $403,000 in ambulatory care settings22,23
Bar Code Electronic Medication Administration System (eMAR) Technology: 51% reduction in medication errors Annual savings of $2.2 million in a large academic
hospital24,25• Computerized Physician Order Entry (CPOE):– Reduced serious medication errors by
81%26
Notes22. Kaushal, R., Kern, L.M., Barrón, Y., et al. (2010). Electronic prescribing improves medication safety in community-based office practices. J Gen Intern Med, 25(6), 530-536.23. Weingart, S.N., Simchowitz, B., Padolsky, H., et al. (2009). An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care. Arch Intern Med, 169(16), 1465-1473.24. Poon, E.G., Keohane, C.A., Yoon, C.S., et al. (2010). Effect of bar-code technology on the safety of medication administration. N Engl J Med, 362(18),1698-1707.25. Maviglia, S.M., Yoo, J.Y., Franz, C., et al. (2007). Cost-benefit analysis of a hospital pharmacy bar code solution. Arch Intern Med, 167(8), 788-794.26. Bates, D.W., Teich, J.M., Lee, J., et al. (1999). The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc, 6(4), 313-321.
Clinical Effectiveness of Safe PracticesIntervention Results
Physician computer order entry 81% reduction of medication errors
Pharmacist rounding with team 66% reduction of preventable adverse drug events; 78% reduction of preventable adverse drug events
Rapid response teams Cardiac arrests decreased by 15%
Team training in labor and delivery 50% reduction in adverse outcomes in preterm deliveries
Reconciling medication practices upon hospital discharge
90% reduction in medication errors
DRUG CONCENTRATION Failure to include concentration in
prescription can result in wrong dose being dispensedamoxicillin suspension 1/2 tsp (2.5 mL) TID Concentration?
“1 amp,” “1 vial,” “1 cap” unclearmultiple strengths, doses, or vial sizes
Order for one “vial” of magnesium sulfate?2 mL vial (8 mEq)20 mL vial (16 mEq)10 mL vial of 50% concentration (40 mEq)
ILLEGIBLE HANDWRITING Handwriting of physicians is subject of
jokesno laughing matter
Unclear orders should be clarified Use standardized, preprinted order
forms Computer generated & typewritten
labels Use of upper- and lowercase lettering
(TALLman)
MISSING INFORMATION Lack of medical information about
patient may cause errorage weight allergies diagnosis indication & severity of condition
HUMAN ERROR(MISTAKES, SLIPS, LAPSES)
Error is inevitable due to “our” limitations:- limited memory capacity- limited mental processing capacity- negative effects of fatigue other stressors
We all make errors all the time Patients suffer adverse events much more
often than previously realised Errors often NOT immediately observed
CONCLUSIONS Human beings will always make errors
Errors are common in medicine, killing tens of thousands
Naming, blaming and shaming have no remedial value
THANK YOU
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