Prepared by: Abdullhadi Burzangy. Introduction In USA, Institute of Medicine report on medication errors (2000): Medical errors: 8 th leading cause.

Prepared by:

Abdullhadi Burzangy

IntroductionIntroduction

In USA, Institute of Medicine report on medication errors (2000):

Medical errors: 8th leading cause of death, resulting in 44,000 - 98,000 deaths annually. In contrast, Highway accidents: 43,458 Breast cancer: 42,297,AIDS: 16,516.

Medication errors account for an estimated 7,000 deaths & injure approximately 1.3 million people per year nationally.

Definition of “medication error”Definition of “medication error”

"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm.

Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and; compounding; dispensing; distribution; administration and use."

• Patients injured as a result of a medication error stay in a hospital longer and have higher hospital costs.

• It costs $17-$29 billion annually.

Cost of medication errorsCost of medication errors

Cost of medication errorsCost of medication errors

• At the hospital in Utah, adverse drug events caused complications in 2.4% of admissions, cost an average of $2,262 per patient, and lengthened the stay by 1.9 days compared with matched controls.

Medication ErrorsMedication Errors

• Medication errors can occur anywhere in these areas:

Prescribing.Repackaging.Dispensing.Administering.

Storage.

The intensity of careThe intensity of care also affects the risk also affects the risk of injury. Among pediatric patients of injury. Among pediatric patients admittedadmitted to a British university hospital, to a British university hospital, drug errors were drug errors were 7 times7 times more likely more likely to to occur in the occur in the intensive care unitintensive care unit than than elsewhereelsewhere

Types of errorsTypes of errors• Wrong drug.• Wrong dose.• Missed dose.• Wrong dosing frequency.• Wrong dosage form.• Wrong time.• Wrong route. • Wrong I.V. rate• Wrong I.V. solution.

Types of errorsTypes of errors• Wrong patient.• Failure to account for patient

characteristics in making drug therapy decision.

• Inappropriate indication for use.• Calculations ,decimal points, unit of

measure.• Known allergy.• Expired date .• Drug interaction.

Common causes of such errors includeCommon causes of such errors include: :

• Poor communication.

• Ambiguities in product names, directions for use, medical abbreviations or writing.

• Patient misuse because of poor understanding of the directions for use of the product .

• Work load (30 prescription order/hour).

Causes of medication Causes of medication errorerror

• Doctors orders change frequently.

• Names of medicines are similar.• Pharmacy delivers incorrect

dose.• Doctor notes is not clear.

Causes of medication Causes of medication errorerror

• Patients on similar medicines.• No communication when next

dose due.• Look alike medicines.• Look alike packaging.

Prescription writingPrescription writing The following important points should be noted:

• Prescription must be printed in English without abbreviations.

• Name of the drug should be written clearly &not abbreviated.

• Dose & dose interval must be stated.

1. Computer issued :

• The dose will be in numbers ,frequency in words &quantity in number in practice. e.g. Amoxycillin cap. 500mg one cap. three times daily (21).

2. Hand-written:

• Quantities to be supplied may be stated by indicating the number of days required for a treatment e.g. Rx Paracetamol tab. 500mg 2×3×7.

• Microgram & nanogram should not be abbreviated.• The unnecessary use of decimal points should be avoided:

• If the decimal point cannot be avoided as for value less than 1, write zero before the value. E.g. 0.5ml not .5 ml.

for liquid , we use milliliter (ml) not cc or Cm3.

Quantities in RxCorrect methodWrong way

1- 1 gram or more.2 g2.0 g

2- less than1gram& more than 1 milligram.

100 mg0.1g

3- less than 1 milligram, written in microgram

100 microgram0.1mg or 100 μg

Table 1. Commonly Misinterpreted Medical Abbreviations

AbbreviationIntended MeaningPossible Misinterpretation

UUnitsMistaken as a zero or a four (4) resulting in overdose.

µgMicrogramsMistaken for "mg" resulting in a 1,000-fold overdose.

QDEvery dayThe period after the "Q" has sometimes been mistaken for an "I," and the drug has been given QID rather than daily.

QODEvery other dayMisinterpreted as "QD" or "QID." If the "O" is poorly written, it looks like a period or an "I."

SC or SQSubcutaneousMistaken as "SL" (sublingual) when poorly written.

TIWThree times a weekMisinterpreted as "three times a day" or "twice a week."

D/CDischarge; also discontinuePatients' medications have been prematurely discontinued when "D/C" was intended to mean "discharge" versus "discontinue."

HSHalf strengthMisinterpreted as the abbreviation "HS" (hour of sleep).

ccCubic centimetersMistaken as "U" (units) when poorly written.

AU, AS, ADBoth ears; left ear; right earMisinterpreted as the abbreviation "OU" (both eyes); "OS" (left eye); "OD" (right eye).

ReportingReporting

Human beings make mistakes.

Mistakes can be prevented by designing systems “that make it hard for people to do the wrong thing and easy for people to do the right thing.”

To design such systems and evaluate their effectiveness, we need to start with baseline information.

Benefits of reporting medication Benefits of reporting medication errorserrors::

*To decrease the incidence of medication errors.

*For Patients safety.

* To improve each step in the medication delivery process.

Benefits of reporting medication Benefits of reporting medication errorserrors::

*To improve clinical practice and quality of care.

*To Educate patients regarding strategies to prevent medication errors.

*To maximize the safe use of medications.

Benefits of reporting medication Benefits of reporting medication errorserrors::

*Identify gaps in research that hinder the understanding of medication errors.

*Promote research to expand knowledge

regarding medication errors, their causes, and the effectiveness of interventions.

Medication-error ReportingMedication-error Reporting

Reporting of medication errors is crucial …but traditionally punitive.

If reporting is inadequate, we cannot identify problems.

Studies conclude that 45-95% of medication errors are not reported.

Why are medication errors not Why are medication errors not reportedreported??

• Administration looks at individual not system.

• Nurses are blamed if something happen to patient due to error.

• Nurses fair adverse consequences from reporting

• Nurses believe peers will think them incompetent .

• Nurses don’t think error is important enough.

Why are medication errors not Why are medication errors not reportedreported??

• Patient / family may sue.

• No positive feedback when medication given correctly.

• Response from administration dose not match the severity.

• Report takes too long to complete.

Medication error reportingMedication error reporting

• Increase awareness of reporting system available to or within health care organization .

• Stimulate & encourage reporting of medication errors both locally &nationally.

• Develop standardization &classification for the collection of medication errors reports so that data base will reflect reports &grading system.

• Maintain system to support & provide feedback to reporters so that appropriate prevention strategies can be developed in facilities.

Medication error preventionMedication error prevention

• Encourage standardization of error-prone aspect of prescribing, delivering & administrating.

• Encourage reliance on system-based solutions to enhance the safety of medication use & to minimize the potential for human error.

• Explore the potential for computer-based information systems in the prevention of medication error.

Medication error preventionMedication error prevention

• Increase awareness of the need for distinctive packaging, labeling& nomenclature of product associated with actual or potential medication error.

• Educate consumers and patient regarding strategies to prevent medication error for both prescription and nonprescription medication.

• Educate health care professional regarding strategies to prevent medication error .

Medication error preventionMedication error prevention

• Presence of a drug information service.

• Pharmacist-provided drug protocol management.

• Pharmacist-participation in medical rounds.

• Increase staffing of clinical pharmacist.

Medication error prevention

• Pharmacists fill no more than 15 prescriptions / hour.

• Avoid verbal drug orders.

• Avoid abbreviations.

• Use of medication-dispensing machines.