medication safety
TRANSCRIPT
PRESENTED BY:SHYAMU MANDAL
ANJU JOSHI
MEDICATION SAFETY
INTRODUCTION
Medication safety has long been recognized to be important in the provision of patient care. . With the evidence now pointing to medication errors as one of the leading causes of avoidable complications and deaths, there is a pressing need for a better understanding of the nature and scope of medication errors,and the will to improve the current clinical delivery systems.
Medication errors occur in all health care settings. Findings from several studies of large numbers of hospitalised patients indicated that each year many patients are harmed, injured or experienced adverse drug events as a result of medication errors.
DEFINATION OF MEDICATION ERROR
The term medication error has been defined in many ways. The US National Co-ordinating Council for Medication Error Reporting and Prevention defines it as:
“ any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer.”
Medication errors may be related to professional practice, products, procedures, environment or systems. They may involve prescribing and ordering; dispensing and distribution; preparation and administration; labelling, packaging and nomenclature; communications and education; or use and monitoring of treatment.
An adverse drug event is defined as an injury resulting from drug-related interventions. It can include prescribing errors, dispensing errors and medication administration errors. Adverse drug events are costly and result in significant additional health care resource consumption.
FACTS ABOUT MEDICATION ERRORS
Between 1993 and 1998, the US food and drug administration adverse event reporting system recorded 5307 medication error reports. The findings were: Medication errors were fatal in 9.8% cases. 48.6% of deaths occurred in patients greater than 60
years old. The three most common causes of death were
improper dose, wrong drug, and wrong route of administration; collectively these represented approximately 66% of all deaths assosiated with medication errors.
The institute of medicine reported that in the US, 7000 deaths occur yearly due to medication errors. Medication errors account for one out of 131
outpatient death and one out of 854 inpatient deaths.
Bates et al. reported that 42% of Adverse Drug Events were preventable and were caused by: Ordering errors(56%) Administration errors(34%) Transcription errors(6%) Dispensing errors(4%)
The medication use process includes:
1. Prescribing2. Dispensing3. Administering4. Monitoring of medicines.Note: these steps may be carried out by health-careworkers or the patient; e.g. self-prescribing over-
thecounter medication and self-administering
medication atHome.
Prescribing involves …
choosing an appropriate medication for a given clinical situation taking individual patient factors into account such as allergies
selecting the administration route, dose, time and regimen
communicating details of the plan with: whoever will administer the medication (written-
transcribing and/or verbal) and the patient
documentation
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, ambiguousmathematical error when calculating dosage incorrect data entry when using computerized
prescribing e.g. duplication, omission, wrong number
SOME EXAMPLES OF PRESCRIBING ERRORS
Look-a-like and sound-a-like medications
Celebrex (an anti-inflammatory)Cerebryx (an anticonvulsant)Celexa (an antidepressant)
14
SAFER!...Make sure the decimal point is OBVIOUS!
Missing the point entirely!
A line may interfere with the observation of a decimal point. The order for 20.4 mg of Cisplatin (chemotherapy) was interpreted as 204 mg, resulting in a ten fold overdose and death.
15“U” is easily mistaken for “4” or “0”
An accident waiting (impatiently) to happen!!
60 units of insulin were given, not 6!!
SAFER!...WRITE OUT “UNITS”
BASIC PRINCIPLES OF PRESCRIBING SAFELY
1. Before prescribing: Assess the patient thoroughly, making sure the
drug is appropriate and not contraindicated . Always ask if the patient is allergic to any drugs;
if this is not already documented, write it down. Take into consideration any medication the patient
is already taking, checking there are no interactions .
2. When prescribing: Check that you are prescribing the correct
medication to the correct patient . Use generic drug names rather than brand
names. Don't use abbreviations. Check the dose, frequency, and route of
administration are correct and appropriate for the patient. Include a start date and a review date.
Avoid unnecessary zeros (for example, 1.0 mg), which may be misread, and make sure the units you use are correct.
If in doubt, refer to appropriate reference Make sure your prescription is legible and easy to
read. Explain what you are prescribing to the patient and
why; describing how and when to take medication increases compliance and reduces confusion.
3. After prescribing:
Watch out for any unprecedented reactions . Review the indications for the drug regularly. This
prevents patients from taking medications they don't need to take.
Dispensing involves…..
reviewing and processing the order, compounding/ preparation of the drug and dispensing the drug in a timely manner.
Source of error in dispensing
Basic principles of dispensing safely:
1. During processing of order (typing, picking and packing):
Interpret prescription carefully to identify any ambiguity or safety concerns.
Do not hesitate to contact prescriber for any illegible or ambiguous order.
Remind prescriber to avoid using dangerous abbreviations when detected on order.
Check that you are entering the correct order into the correct patient profile.
Do NOT ignore warnings or alerts on allergy, drug interactions, contra-indications when entering order into computer system.
Make sure drug label information contains the correct patient name, drug, strength, quantity, dosage instructions and cautionary instructions.
2. During dispensing: Check that you are dispensing the correct drug to
the correct patient. Always ask if patient is allergic to any drugs.
Take into consideration any medication the patient is already taking, including Traditional Chinese Medicine, so as to identify any potential drug-drug interactions.
Caution patient on possible food-drug interactions. Explain clearly to patient what is the drug for, how
and when should it be taken and what are the adverse drug reactions to look out for.
Keep up-to-date references, including on-line version, easily accessible for quick reference check when in doubt.
Administration involves …
obtaining the medication in a ready-to-use form; may involve counting, calculating, mixing, labeling or preparing in some way
checking for allergiesgiving the right medication to the right
patient, in the right dose, via the right route at the right time
Documentation.
How can drug administration go wrong?
wrong patientwrong routewrong timewrong dosewrong drugomission, failure to administerinadequate documentation
Basic principles of administering medication safely………..
1. Before administration: Check that you are taking the correct medication
chart for the correct patient. Interpret the order carefully before preparing drug
for administration. Check that the pharmacist has reviewed a new drug
order before administering. Check for any drug allergy or ambiguous order.
Do not hesitate to contact the prescriber for any illegible or ambiguous order.
Check that you are preparing the correct drug for the correct patient.
Always get a double-check for correct drug, dose, route and time of administration before administering the drug.
Be familiar with all the different administration sets and devices available in the inventory.
2. During administration: Check that you are administering the correct
drug to the correct patient. Advise patients on the possible adverse drug
reactions that they may experience during and after administration.
Encourage patient to express any discomfort or problems experienced during drug administration.
3. After administration: Document promptly on the medication chart the
time that the drug is administered.
Monitoring involves …
observing the patient to determine if the medication is working, being used appropriately and not harming the patient
Documentation.
How can monitoring go wrong?
lack of monitoring for side-effectsdrug not ceased if not working or course
completedrug ceased before course completeddrug levels not measured, or not followed up
oncommunication failures
Basic principles of monitoring medication use……
Be familiar with the drug use protocols Be familiar with the possible adverse drug reactions
following drug administration Be vigilant when monitoring patient by adhering strictly to
established protocols Alert prescriber promptly should patient develop unexpected
signs and symptoms or is not responding as expected Document patient’s response on the medication chart in a
timely manner Do not use dangerous abbreviations when documenting
administration details Keep up-to-date references easily accessible for quick checks
Which patients are most at risk of medication error?
patients on multiple medicationspatients with another condition, e.g. renal
impairment, pregnancypatients who cannot communicate wellpatients who have more than one doctorpatients who do not take an active role in
their own medication usechildren and babies (dose calculations
required)
In what situations are staff most likely to contribute to a medication error?
inexperiencerushingdoing two things at onceinterruptionsfatigue, boredom, being on “automatic
pilot” leading to failure to check and double-check
lack of checking and double checking habitspoor teamwork and/or communication
between colleaguesreluctance to use memory aids
How can workplace design contribute to medication errors?
absence of a safety culture in the workplace e.g. poor reporting systems and failure to learn from
past near misses and adverse eventsabsence of memory aids for staff inadequate staff numbers
Performance requirements
What you can do 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 use memory aids communicate clearly develop checking habits encourage patients to be actively involved report and learn from errors
Tailor your prescribing for each individual patient
Consider: allergies co-morbidities (especially liver and renal
impairment) other medication pregnancy and breastfeeding size of patient
Know which medications are high risk and take precautions
narrow therapeutic window multiple interactions with other medications potent medications complex dosage and monitoring schedules examples:
oral anticoagulants Insulin chemotherapeutic agents neuromuscular blocking agents aminoglycoside antibiotics intravenous potassium emergency medications (potent and used in high pressure
situations)
Use memory aids
textbookspersonal digital assistantcomputer programmes, computerized
prescribingprotocolsfree up your brain for problem solving rather
than remembering facts and figures that can be stored elsewhere
looking things up if unsure is a marker of safe practice, not incompetence!
Remember the 5 Rs when prescribing and administering
Can you remember what they are?right drugright doseright routeright timeright patient
Communicate clearly
the 5 Rsstate the obviousclose the loop
Develop checking habits
when prescribing a medicationwhen administering medication:
check for allergies check the 5 Rs
remember computerized systems still require checking
always check and it will become a habit!
Encourage patients to be actively involved in the process
when prescribing a new medication provide patients with the following information: name, purpose and action of the medication dose, route and administration schedule special instructions, directions and precautions common side-effects and interactions how the medication will be monitored
encourage patients to keep a written record of their medications and allergies
encourage patients to present this information whenever they consult a doctor
Report and learn from medication errors
Summary
medications can greatly improve health when used wisely and correctly
yet, medication error is common and is causing preventable human suffering and financial cost
remember that using medications to help patients is not a risk-free activity
know your responsibilities and work hard to make medication use safe for your patients
Example case
a 74-year-old man sees a community doctor for treatment of new onset stable angina
the doctor has not met this patient before and takes a full past history and medication history
he discovers the patient has been healthy and only takes medication for headaches
the patient cannot recall the name of the headache medication
the doctor assumes it is an analgesic that the patient takes whenever he develops a headache
Example case
but the medication is actually a beta-blocker that he takes every day for migraine; this medication was prescribed by a different doctor
the doctor commences the patient on aspirin and another beta-blocker for the angina
after commencing the new medication, the patient develops bradycardia and postural hypotension
unfortunately the patient has a fall three days later due to dizziness on standing; he fractures his hip in the fall
What factors contributed to this medication error?
two drugs of the same class prescribed unknowingly with potentiation of side-effects
patient not well informed about his medicationspatient did not bring medication list with him
when consulting the doctordoctor did not do a thorough enough
medication historytwo doctors prescribing for one patientpatient may not have been warned of potential
side-effects and of what to do if side-effects occur
Case
a 38-year-old woman comes to the hospital with 20 minutes of itchy red rash and facial swelling; she has a history of serious allergic reactions
a nurse draws up 10 mls of 1:10,000 adrenaline (epinephrine) into a 10 ml syringe and leaves it at the bedside ready to use (1 mg in total) just in case the doctor requests it
meanwhile the doctor inserts an intravenous cannula
the doctor sees the 10 ml syringe of clear fluid that the nurse has drawn up and assumes it is normal saline
Casethere is no communication between the doctor
and the nurse at this timethe doctor gives all 10 mls of adrenaline
(epinephrine) through the intravenous cannula thinking he is using saline to flush the line.
the patient suddenly feels terrible, anxious, becomes tachycardic and then becomes unconscious with no pulse
she is discovered to be in ventricular tachycardia, is resuscitated and fortunately makes a good recovery
recommended dose of adrenaline (epinephrine) in anaphylaxis is 0.3 - 0.5 mg IM, this patient received 1mg IV
Can you identify the contributing factors to this error?
assumptionslack of communicationinadequate labeling of syringegiving a substance without checking and
double-checking what it islack of care with a potent medication
How could this error have been prevented?
never give a medication unless you are sure you know what it is; be suspicious of unlabelled syringes
never use an unlabelled syringe unless you have drawn the medication up yourself
label all syringescommunication - nurse and doctor to keep each
other informed of what they are doing e.g. nurse: “I’m drawing up some adrenaline”
develop checking habits before administering every medication … go through the 5 Rs e.g doctor: “ What is in this syringe?”
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