By Ruth Kavita Senior Pharmaceutical Technologist, KNH.

By Ruth KavitaSenior Pharmaceutical Technologist, KNH

Introduction

• Medication error is any preventable event that may cause, or has caused patient harm while the medication is in control of a health care professional (e.g. Doctor, Pharmacist, Nurse) or patient.

Medical errors are not defined as intentional acts of wrongdoing

Not all medical errors rise to the level of medical malpractice and negligence.

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Stages of medical errors

There are different stages in which a medication error can happen:

Prescribing of medicationDispensing of medicationAdministration of medication

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Prescribing stage of medicationPotential errors include:Ordering the incorrect doseOrdering the incorrect drugOrdering the wrong interval or scheduleOrdering the wrong route of administrationOrdering the wrong rateOrdering the wrong dose form (tabs, liquid)Use of abbreviations and decimal points

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Prescribing stage of medication cont’d

• Handwriting that is illegible• Incomplete orders• Ordering and not being alert to allergies• Ordering without reviewing and being aware of

current medications patient is taking resulting in adverse reactions

Wrong transcription e.g Lanoxin vs Laroxyl Wrong calculation

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Sound- alike anticancer

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Prevention of errors at prescribing stage

Educating the prescriber Educating the nurseCompleting a thorough assessment of the

patient’s history including allergies and current medications

Clarifying orders that are illegible Review by the consultant pharmacist of

medication profiles.

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Dispensing phasePotential errors include:Dispensing the wrong drug, wrong dose,

wrong quantitiesInaccurate directions for use of medicationsFailure to educate patient on use of medication Incorrect labelingDispensing an expired medication Dispensing without knowing patient allergiesDispensing to the wrong patient

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Look-alike drug labels

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Similar packaging antihypertensives

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Prevention of errors at dispensing stage

• Counterchecking dispensed medications• Checking the expiration dates on drugs• Checking the integrity of the drug• Be clear of proper use of the drug• Clear concise instructions for medication

usage • Clarifying all questionable orders• Knowing what the drug is used for • Know patient allergies

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Administration of medications stage

Potential errors include:Omitting medicationsNot shaking a medication that should beWrong storageCrushing medications not intended to be crushedUse of inappropriate diluentsAdministering the wrong medicationsIncomplete container deliveryAdsorption (container / IV sets)

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Storage of different drugs together

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Similar packaging

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Look-alike antibiotics

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Factors that contribute to the occurrence of medical errors

DistractionsStressIncreased workloadLack of educationFailure to follow policy and proceduresPoor tracking systems to identify cause and

prevention of errors

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9 “Rights” to effective prevention of medication errors

Right patient Right drugRight routeRight time Right dose Right documentationRight action Right form Right response

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Case studies- KNH 1. Findings of medication errors in oncology

pharmacy -March to December 2010 Figure 1: Type of Errors

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Case studies Cont’d

25 5 6

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19 19

2528

4851

0

10

20

30

40

50

60

1

Type of error

Nu

mb

er

No Dose

BSA calculation

Wrong route

Interaction

Contraindication

Required med notprescribedWrong Medicine /RegimenPremeds missing

Lower doses

Higher doses

Frequency / duration

Figure 2: Description of prescribing errors

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2. Summary of interventions at Pharmacy 8 for the month of February, 2012

INTERVENTION ON HIGH LOW % FREQUENCY OF DOSING 17 09 45.61

DOSE 04 01 8.77 DRUG INTERACTIONS 11 19.29 DURATION OF TREATMENT - - ALLERGIES 02 3.50 CONTRAINDICATIONS 03 5.26 COMBINATIONS 10 17.54 TOTAL NO. OF INTERVENTIONS

57 100

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3. Summary of errors at IP ART Pharmacy between March and April 2014

March…………40April…………..39Most errors and omissions were related to

Age and Weight

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Way forwardStrengthen system for reporting medication

errorsComprehensive education and training of all

involved staffDifferent storage areas for important drugs

(e.g. concentrated potassium chloride)Use of technology e.g automated dispensing

cabinets, more advanced infusion devices, electronic prescribing

Increasing manpower22

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