on med error

Medication Errors Medication Errors -- the Annual Toll:the Annual Toll:

FACTS:FACTS:

In 2008 In 2008 -- 3.5 Billion Prescriptions were written, filled and dispensed in3.5 Billion Prescriptions were written, filled and dispensed in USUS

1% error rate or 35 Million 1% error rate or 35 Million ““Medication ErrorsMedication Errors”” occurred in Hospitals, occurred in Hospitals, SNFsSNFs, at , at homehome

““Medication ErrorsMedication Errors”” cause 1,000,000 serious injuries annually cause 1,000,000 serious injuries annually

““Medication ErrorsMedication Errors”” cause 100,000 deaths annually cause 100,000 deaths annually

More deaths annually in U.S. from Medication Errors than auto More deaths annually in U.S. from Medication Errors than auto accidents and accidents and work place injuries work place injuries combinedcombined

Nearly all medication errors are preventable.Nearly all medication errors are preventable.

The The Elderly Elderly and and ChildrenChildren are at greatest risk for serious injury due to are at greatest risk for serious injury due to medication errorsmedication errors

�� Source: Source: Institute of Medicine, National Academy of Sciences. Institute of Medicine, National Academy of Sciences. �� Preventing Medication Errors Report Preventing Medication Errors Report

ConventionaConventionall Wisdom / Statement of the ObviousWisdom / Statement of the Obvious

MMost serious medication errors result from administration of ost serious medication errors result from administration of either: either:

�� the wrong drug or medication;the wrong drug or medication;

�� in the wrong dosage;in the wrong dosage;

�� to the wrong patient; to the wrong patient;

�� at the wrong time. at the wrong time.

Or a combination of any of all of these eventsOr a combination of any of all of these events

2 Objectives of this Web Seminar:2 Objectives of this Web Seminar:

Identity 12 Identity 12 specific types of medication errorsspecific types of medication errors made dailymade daily

in hospitals, pharmacies, nursing homes and in medicalin hospitals, pharmacies, nursing homes and in medical

offices and clinicsoffices and clinics

Provide tips, medical resources and litigation tools Provide tips, medical resources and litigation tools

that savvy PI injury attorney can use to recognize,that savvy PI injury attorney can use to recognize,

investigate and successfully (and cost effectively) litigateinvestigate and successfully (and cost effectively) litigate

and settle these serious injury or death cases. and settle these serious injury or death cases.

THE TOP 12 LISTTHE TOP 12 LIST : :

1. Allergic / Anaphylactic Reactions2. Narcotic pain medication “over dosage”3. Anti-coagulant (Coumadin) dosage error4. Insulin administration error5. Adverse Medication “Interactions”6. Pharmacy dispensing errors7. Inadequate warnings or instructions8. Drug infusion pump programming error9. Miscalculation of proper pediatric dosage10. Confusing drug packaging11. “Similar Drug Name” Confusion12. Use of error prone abbreviations

1.1. Allergic / Anaphylactic ReactionsAllergic / Anaphylactic Reactions

Physiology of a drug Physiology of a drug ““allergic reactionallergic reaction””

�� A person may have a genetic predisposition or sensitivity to a A person may have a genetic predisposition or sensitivity to a

specific medication, or have a limited tolerance specific medication, or have a limited tolerance

�� When a person is 1When a person is 1stst exposure to a drug to which he/she has a exposure to a drug to which he/she has a

““sensitivitysensitivity””, their immune system produces an antibody, , their immune system produces an antibody,

(immunoglobulin E or (immunoglobulin E or IgEIgE) which is stored on special cells) which is stored on special cells

�� When a person is exposed to the drug again, or in amounts in When a person is exposed to the drug again, or in amounts in

excess of their tolerance levels, the antibodies can trigger reexcess of their tolerance levels, the antibodies can trigger release lease

of chemicals called of chemicals called ““mediatorsmediators”” which can trigger a widespread which can trigger a widespread

systemic reaction to the drug, called an systemic reaction to the drug, called an ““allergic reaction.allergic reaction.””

�� Most severe reactions can be cardiac, pulmonary or skin reactionMost severe reactions can be cardiac, pulmonary or skin reactionss

�� Anaphylactic reactionAnaphylactic reaction (shock) severe reaction to a drug to which (shock) severe reaction to a drug to which

a person has an extreme sensitivitya person has an extreme sensitivity

Anaphylactic ReactionAnaphylactic Reaction

�� Serious allergic reaction Serious allergic reaction -- can be life threatening.can be life threatening.

�� Characteristics of anaphylaxis / anaphylactic shock include:Characteristics of anaphylaxis / anaphylactic shock include:

�� Severe Skin reaction: Hives, itching, redness/flushing, waSevere Skin reaction: Hives, itching, redness/flushing, warmth, (S.J.S)rmth, (S.J.S)

�� Cardiac reaction:Cardiac reaction: Arrest, tachycardia, abnormal cardiac rhythmArrest, tachycardia, abnormal cardiac rhythm

�� Respiratory reaction: SOB, wheezing, throat tightness, Respiratory reaction: SOB, wheezing, throat tightness, tachypneatachypnea

�� Circulatory reaction:Circulatory reaction: Loss of consciousness, syncope (fainting),Loss of consciousness, syncope (fainting),

due to hypotension (decrease in blood pressure) due to hypotension (decrease in blood pressure)

�� Edema / Swelling :Edema / Swelling : Face, tongue, lips, throat, joints, hands, or feetFace, tongue, lips, throat, joints, hands, or feet

�� Most occur within one hour of taking the drug, and many occur wiMost occur within one hour of taking the drug, and many occur within thin minutes or even seconds.minutes or even seconds.

�� Requires immediate examination and treatment in a hospital ER Requires immediate examination and treatment in a hospital ER

�� Medical Medical TxTx ::

AntiAnti--histamines (Benadryl), steroids (Prednisone), Epinephrinehistamines (Benadryl), steroids (Prednisone), Epinephrine

Most Common Drugs Allergies:Most Common Drugs Allergies:

�� Painkillers (analgesics) Painkillers (analgesics) �� Narcotics: morphine, codeine, Narcotics: morphine, codeine, demeroldemerol, , hydrocodonehydrocodone, , etc.etc.

�� NSAIDS (nonNSAIDS (non--steroidal antisteroidal anti--inflamatoryinflamatory drugs)drugs)

�� Aspirin, Ibuprofen, Aspirin, Ibuprofen, indomethacinindomethacin

�� Antibiotics:Antibiotics:�� PenicillinPenicillin

�� Sulfa drugs (Sulfa drugs (SeptraSeptra, , BactrimBactrim) )

�� Erythromycin Erythromycin

�� TetracycliclineTetracyclicline

�� AntiseizureAntiseizure medicationsmedications�� DilantinDilantin , , TegretolTegretol and othersand others

Meritorious Allergic Reaction CasesMeritorious Allergic Reaction Cases::Prescription or administration of drug to which patient has a knPrescription or administration of drug to which patient has a known or own or documented allergy or reaction:documented allergy or reaction:

-- Patient questionnaire, intake forms: allergies?Patient questionnaire, intake forms: allergies?

-- Family Family HxHx of medication allergy or reaction?of medication allergy or reaction?

-- Patient wrist band / MedicPatient wrist band / Medic--alert braceletalert bracelet

-- Hospital admission formsHospital admission forms

-- Stickers on office / hospital chart (RTPD Stickers on office / hospital chart (RTPD -- original )original )

-- EMR (electronic medical records)EMR (electronic medical records)

-- Anesthesia record / chartAnesthesia record / chart

““Serious injurySerious injury”” requiring hospitalization / extended treatmentrequiring hospitalization / extended treatment

““Cross ReactivityCross Reactivity”” issues: issues:

Brand Name vs. Generic Name issues Brand Name vs. Generic Name issues

–– different different ““inactive ingredientsinactive ingredients”” to which Pt may be allergicto which Pt may be allergic

2. 2. Narcotic pain medication Narcotic pain medication ““over dosageover dosage””

�� Narcotic pain relieversNarcotic pain relievers –– ““OpioidsOpioids”” include:include:�� Morphine, Morphine, demeroldemerol, codeine, , codeine, hydrocodonehydrocodone, , dilaudiddilaudid, , oxycontinoxycontin

�� Among most commonly prescribed medications today Among most commonly prescribed medications today

�� Used to Used to TxTx moderate to severe chronic & acute painmoderate to severe chronic & acute pain

�� Physiological effectsPhysiological effects::�� Central nervous system depressionCentral nervous system depression

�� Profound respiratory depressionProfound respiratory depression

�� Nausea, vomiting , possible aspiration of emesesNausea, vomiting , possible aspiration of emeses

�� Possible InjuriesPossible Injuries::�� DeathDeath

�� Hypoxic brain injuryHypoxic brain injury

�� Aspiration pneumonia, pulmonary infectionsAspiration pneumonia, pulmonary infections

Meritorious narcotic Meritorious narcotic ““overdoseoverdose”” casescases::

-- Wrong (excessive) dose administeredWrong (excessive) dose administered

-- Rx: 10 Rx: 10 ““mcgsmcgs”” (micrograms) but 10 (micrograms) but 10 ““mgsmgs”” (milligrams) given(milligrams) given

-- Rx: Rx: ““QDQD”” ( 1 x per day), but med given ( 1 x per day), but med given ““QIDQID”” (4x / day)(4x / day)

-- FentanylFentanyl transdermaltransdermal patch leakpatch leak

-- Symptoms of respiratory distress misinterpreted as pain Symptoms of respiratory distress misinterpreted as pain

response, and RN administered additional narcoticresponse, and RN administered additional narcotic

-- Multiple careMultiple care--givers fill same order ( 3 pain shots in ER)givers fill same order ( 3 pain shots in ER)

-- Incorrect dosage instructions typed on bottle by pharmacyIncorrect dosage instructions typed on bottle by pharmacy

technician technician -- ““apply 1 patch every 3 hoursapply 1 patch every 3 hours””

-- should have been should have been ““ 1 every 3 days1 every 3 days””

-- Excessive pediatric dosageExcessive pediatric dosage

-- OD due to OD due to ““SynergesticSynergestic”” multiplier effect of other meds, multiplier effect of other meds,

3. Coumadin / Heparin Anti3. Coumadin / Heparin Anti--coagulant Dosage Errorcoagulant Dosage Error

�� Anticoagulants / AntiAnticoagulants / Anti--Thrombotic Thrombotic TxTx prescribed for a variety of prescribed for a variety of

conditions:conditions:

�� Treatment of current DVT, PE, Venous Treatment of current DVT, PE, Venous thromboemboismthromboemboism

�� Cardiac rhythm disturbance: Cardiac rhythm disturbance: AtrialAtrial fibrilationfibrilation

�� Prosthetic heart valve Prosthetic heart valve

Significant risks of anticoagulantsSignificant risks of anticoagulants::�� If blood level too high (If blood level too high (supratheraputicsupratheraputic) ) -- significant risk of bleeding significant risk of bleeding

-- If blood level too low (If blood level too low (subtheraputicsubtheraputic)) -- significant risk of clot/ significant risk of clot/ PePe/ DVT/ DVT

�� INR Monitoring required for patients on anticoagulants INR Monitoring required for patients on anticoagulants

�� Requires regular blood tests Requires regular blood tests ““INRINR”” levels levels

�� ““TargetTarget”” theraputictheraputic range usually 2.0 range usually 2.0 –– 3.5 3.5

�� Often requires frequent / daily dosage adjustmentsOften requires frequent / daily dosage adjustments

Meritorious Coumadin Error CasesMeritorious Coumadin Error Cases::

�� MD fails to order INR labs w/ sufficient frequencyMD fails to order INR labs w/ sufficient frequency

�� Coumadin Clinic failure to promptly communicate INR Coumadin Clinic failure to promptly communicate INR

levels / dose adjustments to patient, nursing homelevels / dose adjustments to patient, nursing home

(typically w/in 2 days of INR check (typically w/in 2 days of INR check -- phone & Fax)phone & Fax)

�� Failure of health care provider / nursing home to Failure of health care provider / nursing home to

diligently follow dose adjustment instructionsdiligently follow dose adjustment instructions

�� MD misinterpreting EMR (electronic med record) INR MD misinterpreting EMR (electronic med record) INR

results and prescribed excessive dosesresults and prescribed excessive doses

�� Pharmacist Pharmacist mismis--calculating proper dose adjustments post calculating proper dose adjustments post

INR ( Is Coumadin clinic using proper protocol?)INR ( Is Coumadin clinic using proper protocol?)

4. 4. Insulin Administration ErrorsInsulin Administration Errors

Insulin an injectable drug diabetics use to control blood sugar Insulin an injectable drug diabetics use to control blood sugar levelslevels

�� Insulin administration errors are associated with serious risks Insulin administration errors are associated with serious risks & complications& complications

�� Insulin administration errors continue to be common in hospitalInsulin administration errors continue to be common in hospitals and s and SNFsSNFs

Most Common Types of Insulin Administration ErrorsMost Common Types of Insulin Administration Errors::

�� Omission Omission errors / missed dose errors / missed dose -- leading to hyperglycemialeading to hyperglycemia

�� Improper dose / quantity Improper dose / quantity -- leading to either hyper or hypo leading to either hyper or hypo glycemiaglycemia

�� Numerous types of insulin products (~ 23 different brands) Numerous types of insulin products (~ 23 different brands)

further amplify the potential for errors to occur.further amplify the potential for errors to occur.

Potential InjuriesPotential Injuries::

-- Diabetic coma / death / cerebral edema / severe neurological inDiabetic coma / death / cerebral edema / severe neurological injuryjury

5. Adverse Medication 5. Adverse Medication ““InteractionsInteractions””

�� Most drugs are metabolized by enzymes in the liver Most drugs are metabolized by enzymes in the liver

�� Drug Drug ““interactionsinteractions”” can occur when one drug interferes with can occur when one drug interferes with

metabolizationmetabolization of another drug by the liverof another drug by the liver

�� This can produce a wide range of adverse reactions:This can produce a wide range of adverse reactions:

Renal failure, seizures, cardiac and pulmonaryRenal failure, seizures, cardiac and pulmonary

�� Many such adverse Many such adverse ““interactionsinteractions”” are recognized and catalogued, are recognized and catalogued,

charted and tracked by pharmacy and hospital computerscharted and tracked by pharmacy and hospital computers

See:See:

Types of drugs that frequently cause adverse Types of drugs that frequently cause adverse ““interactionsinteractions””::

-- Antibiotics: Antibiotics: CiproCipro, Erythromycin, Erythromycin

-- Anticoagulants:Anticoagulants: Heparin & CoumadinHeparin & Coumadin

-- Anticonvulsants:Anticonvulsants: PhenotinPhenotin, Diazepam, Diazepam

-- Cardiac meds:Cardiac meds: DigoxinDigoxin, ,

Meritorious Drug Interaction CasesMeritorious Drug Interaction Cases::�� Physician/hospital failed to obtain or maintain list of Physician/hospital failed to obtain or maintain list of

-- PatientPatient’’s current medicationss current medications

-- PatientPatient’’s past medication reactions (if any) s past medication reactions (if any)

-- Family Family HxHx of any medication reaction/interactionof any medication reaction/interaction

�� Physician knowledge deficit re meds most likely to Physician knowledge deficit re meds most likely to

interact with other meds ( anticonvulsants, antibiotics, interact with other meds ( anticonvulsants, antibiotics,

anticoagulants, cardiac meds, insulin)anticoagulants, cardiac meds, insulin)

-- Physician or pharmacist fails to check :Physician or pharmacist fails to check :

-- Pocket / Pocket / iphoneiphone / Blackberry reference source / Blackberry reference source EgEg. . EpocratesEpocrates

-- Computer data base / On line resources for drug interactions Computer data base / On line resources for drug interactions

6. 6. Pharmacy Dispensing ErrorsPharmacy Dispensing Errors

�� From From ’’00 00 –– ‘‘10 growth # of drug prescriptions & # of pharmacies10 growth # of drug prescriptions & # of pharmacies

�� 2008 > 3.5 2008 > 3.5 billion billion prescriptions written & filled in U.S.prescriptions written & filled in U.S.

�� More pharmacies, mores pharmacists, increased reliance on More pharmacies, mores pharmacists, increased reliance on

pharmacy technicians for more complex tasks pharmacy technicians for more complex tasks

�� 1% estimated error rate = 350 million errors !!1% estimated error rate = 350 million errors !!

�� Out Patient pharmacy error rate Out Patient pharmacy error rate higher higher than In Patient error ratethan In Patient error rate

�� More More Pharmacy Drug Dispensing Errors of Pharmacy Drug Dispensing Errors of every typeevery type::

�� Wrong drug ( confusing drug names)Wrong drug ( confusing drug names)

�� Wrong patient ( Patient AWrong patient ( Patient A’’s meds given to Patient B)s meds given to Patient B)

�� Wrong dosage instructions ( # of pills to take per day, # of x Wrong dosage instructions ( # of pills to take per day, # of x to take)to take)

�� Failure to check PtFailure to check Pt’’s other meds s other meds RxRx’’dd for possible interactionfor possible interaction

�� Wrong pills put into bottle with correct label and instructions Wrong pills put into bottle with correct label and instructions for for

prescribed medicationprescribed medication

�� Wrong instruction label put on pill bottleWrong instruction label put on pill bottle

�� Wrong warning / instruction sheet with medication bottleWrong warning / instruction sheet with medication bottle

Litigation tips reLitigation tips re claims vs. Pharmacies:claims vs. Pharmacies:

�� All Chain Pharmacies competing for lucrative businessAll Chain Pharmacies competing for lucrative business

�� All want to avoid negative publicity and headlines about lawsuitAll want to avoid negative publicity and headlines about lawsuitss

�� All want to settle claims expediently and confidentiallyAll want to settle claims expediently and confidentially

�� All will settle All will settle meritorious claimsmeritorious claims as soon as claim documentedas soon as claim documented

Settlement StrategiesSettlement Strategies::

-- Instruct clients to save pills bottles, pills, & warning sheetsInstruct clients to save pills bottles, pills, & warning sheets

-- Request All records from Request All records from RxRx’’inging MD & Pharmacy MD & Pharmacy

-- Request All records & billings from ER, Request All records & billings from ER, TxTx’’inging MDs, Hospital, SNF, etc.MDs, Hospital, SNF, etc.

-- Even Even ““modestmodest”” injuries can be worth pursuing injuries can be worth pursuing

-- Consider written report from Pharmacologist re causation and damConsider written report from Pharmacologist re causation and damages ages

--

-- Detailed preDetailed pre--lit lit ““Demand LetterDemand Letter”” will reap solid resultswill reap solid results

7.7. Inadequate Instructions & Warnings:Inadequate Instructions & Warnings:

�� Multiple Sources of Medication Instructions & Warnings to PatienMultiple Sources of Medication Instructions & Warnings to Patients:ts:

�� Prescribing Physician, NPPrescribing Physician, NP

�� Dispensing PharmacistDispensing Pharmacist

�� Nurses administering medicationsNurses administering medications

�� Hospital, Surgery Center Hospital, Surgery Center ““Patient Discharge InstructionsPatient Discharge Instructions””

�� Drug / Medication Labels and Package InsertsDrug / Medication Labels and Package Inserts

�� PDR, Medication / Drug Texts & Compendiums PDR, Medication / Drug Texts & Compendiums

�� Direct Advertising by drug manufacturerDirect Advertising by drug manufacturer

�� Internet Sources: Range from excellent to Internet Sources: Range from excellent to wrong wrong informationinformation

Basis of Basis of ““InadequateInadequate”” information or warningsinformation or warnings::

�� Confusing, incomplete verbal instructionsConfusing, incomplete verbal instructions

�� Failure to warn of interactions with other meds, OTC, herbs, fooFailure to warn of interactions with other meds, OTC, herbs, foodsds

�� ““MedicaleseMedicalese”” –– polysyllabic medical words and phrasespolysyllabic medical words and phrases

�� ESL ESL –– English as second language for many patientsEnglish as second language for many patients

�� Inconsistent labeling standardsInconsistent labeling standards

�� Confusing, Inconsistent dose , administration instructionsConfusing, Inconsistent dose , administration instructions

�� Illegible small print on drug / medication insertsIllegible small print on drug / medication inserts

Potential MeritoriousPotential Meritorious CasesCases

�� MD, Pharmacist, RN, etc. MD, Pharmacist, RN, etc. -- fails to give any instructions at allfails to give any instructions at all

�� MD, Pharmacist, RN, etc. MD, Pharmacist, RN, etc. -- gives incomplete or wrong infogives incomplete or wrong info�� ““No this medication (Norco) does not contain any .narcoticNo this medication (Norco) does not contain any .narcotic…”…”

�� ““Even if you have reacted to Even if you have reacted to SeptraSeptra, this , this BactrimBactrim is safe for youis safe for you…”…”

�� ““It is safe to use steroid containing It is safe to use steroid containing eyedropseyedrops for up to 6 monthsfor up to 6 months…”…”

�� ““This medication is safe for childrenThis medication is safe for children…………....””

�� Wrong warning label, package insert provided to patientWrong warning label, package insert provided to patient

�� Failure to advise Pt when to stop, discontinue or reduce doseFailure to advise Pt when to stop, discontinue or reduce dose

�� Failure to provide Pt with contact information for questionsFailure to provide Pt with contact information for questions

(especially problematic following hospital, surgery center (especially problematic following hospital, surgery center dischagesdischages))

8. 8. Drug infusion pump programming errorDrug infusion pump programming error

IV Infusion PumpsIV Infusion Pumps ::�� IV Infusion pumps are involved in 1/3 serious med errorsIV Infusion pumps are involved in 1/3 serious med errors

�� IV medication administration error is 3x more likely to IV medication administration error is 3x more likely to cause death or serious injury than oral or IM admincause death or serious injury than oral or IM admin

�� Drug flows directly into blood stream and to critical Drug flows directly into blood stream and to critical organs, with immediate physiological effectorgans, with immediate physiological effect

�� Common programming errors: flow rate, total dosage Common programming errors: flow rate, total dosage

�� Most frequent IV Infusion Pump errors involve:Most frequent IV Infusion Pump errors involve:�� Narcotic pain medications, Insulin & AnticoagulantsNarcotic pain medications, Insulin & Anticoagulants

�� Miscalculation of proper dose, Miscalculation of proper dose, ““ free flowfree flow”” of medsof meds

New New ““Smart PumpSmart Pump”” ProgramsPrograms

More More ““user friendly softwareuser friendly software”” to reduce errorsto reduce errors

More More ““automaticautomatic”” warnings re med, pt, dosages, etc.warnings re med, pt, dosages, etc.

9. 9. Miscalculation of proper pediatric dosage:Miscalculation of proper pediatric dosage:

� Pediatric medication errors are an enormous problem nationally

� Key Factors:

� Meds Instructions frequently give: “adult dose” vs. “child’s dose”

� “Children” vary so much in weight:� Infant or toddler weight may be fraction of 10 yr olds weight

� Lower weight / body mass / intravascular volume means a much narrower margin of error in correct dosage for “children”

� Most drugs - not tested in large #s of children to establish “safe” dosage

� Medication errors occur with same frequency in adults and children

� Serious injuries or death are 7x more common in children

� “Most of serious injuries & deaths prevented if providers wrote orders using computers that included dose checking.“

Source: (Institute for Safe medication Practices 2002 Report )Source: (Institute for Safe medication Practices 2002 Report )

10. Confusing Drug Packaging10. Confusing Drug Packaging

�� Example: Example: LanoxinLanoxin ((DigoxinDigoxin / Digitalis) powerful cardiac drug/ Digitalis) powerful cardiac drug�� The dropper utilizes "cc" for dosingThe dropper utilizes "cc" for dosing

�� The packaging states "The packaging states "mLmL" for milliliters, also references " for milliliters, also references ““mcgmcg”” for for micrgramsmicrgrams

�� Confusing for a patient who may be unaware that 1 cc = 1 Confusing for a patient who may be unaware that 1 cc = 1 mLmL or 1ml = 1000 mcgor 1ml = 1000 mcg

Confusing Drug Packaging: ChildrenConfusing Drug Packaging: Children’’s Tylenols Tylenol

�� Blister package exhibits confusing labelingBlister package exhibits confusing labeling

�� Could accidentally double the typical dose Could accidentally double the typical dose

of medication given to small children. of medication given to small children.

�� Front of the carton states "medicine per Front of the carton states "medicine per

dose 80 mg," dose 80 mg,"

�� Individual blister packs that contain either Individual blister packs that contain either

one or twoone or two

80 mg tablets are all labeled "Children's 80 mg tablets are all labeled "Children's

Tylenol 80 mg" Tylenol 80 mg"

�� OverOver--thethe--counter product of potentially counter product of potentially

high risk medication given to young high risk medication given to young

childrenchildren. .

11. 11. ““Similar Drug NameSimilar Drug Name”” ConfusionConfusionIn U.S. > 10,000 FDA approved In U.S. > 10,000 FDA approved ““prescriptionprescription”” drugsdrugs

>100,000 OTC >100,000 OTC ““over the counterover the counter”” medications availablemedications available

-- MANY of these drugs have similar looking / sounding namesMANY of these drugs have similar looking / sounding names

-- ““Similar Drug NameSimilar Drug Name”” confusion is frequent cause of the confusion is frequent cause of the

““wrong drugwrong drug”” being given to a patient by nurse or pharmacybeing given to a patient by nurse or pharmacy

-- Similar sounding name: Similar sounding name: verbal or telephone order confusionverbal or telephone order confusion

-- Similar looking name: Similar looking name: written prescription confusionwritten prescription confusion

-- Death or serious injury can result from such confusionDeath or serious injury can result from such confusion

Miscalculation of proper pediatric dosage

--www.www.ismpismp.org/Tools/.org/Tools/confuseddrugnamesconfuseddrugnames.pdf.pdf-- 8 page List of 8 page List of ““most frequently confusedmost frequently confused”” drug Names > 600 entriesdrug Names > 600 entries

-- AllegaAllega –– ViagraViagra CedaxCedax -- CidexCidex

-- AlprazolamAlprazolam –– LorazepamLorazepam CozaarCozaar –– ZocorZocor

-- AmicarAmicar -- OmacarOmacar DynacircDynacirc -- DynacinDynacin

-- Aricept Aricept –– AciphexAciphex LunestaLunesta -- NeulastaNeulasta

-- BenazeprilBenazepril –– BenadrylBenadryl PanalorPanalor –– PamelorPamelor

-- FlowmaxFlowmax –– volmaxvolmax Zantac Zantac -- ZyrtecZyrtec

12. 12. Use of error prone abbreviationsUse of error prone abbreviations

� Use of “similar looking” abbreviations leads to frequent errors:

� Wrong dug: “DPT” – demerol, phenergan, tegretol vs.

- diptheria, pertusses, tetanus

� Wrong dosage:� “mg” milligram vs. “mcg” microgram ( 1000 x difference)

� Wrong administration schedule� “qd” 1 each day vs. “qid” 4 x per day (4x difference)

� Wrong location of administration of medication: � OD, OS, OU R eye, L eye, Each eye

� Wrong route / method of drug administration:� IV, IM, IN Intravenous, Intramuscular, Intranasal

Institute for Safe Medication Practices List of error prone Abbreviations, Symbols and Dose Designations:

� http://www.ismp.org/Tools/errorproneabbreviations.pdf

RESOURCES: MEDICATION SAFETY WEBSITESRESOURCES: MEDICATION SAFETY WEBSITES

1.1. Institute for Safe Medication PracticesInstitute for Safe Medication Practices

www.ismp.orgwww.ismp.org

2.2. FDA FDA MedWatchMedWatch

www.fda.gov/medwatch/index.htmlwww.fda.gov/medwatch/index.html

3.3. National Center For Patient SafetyNational Center For Patient Safety

www.patientsafety.govwww.patientsafety.gov

4.4. Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

www.ahrq.govwww.ahrq.gov

5.5. Center for Improving Medication Center for Improving Medication ManagementManagement

www.learnaboutrxsafety.orgwww.learnaboutrxsafety.org

6.6. Consumers Advancing Patient Safety (CAPS)Consumers Advancing Patient Safety (CAPS)

www.patientsafety.orgwww.patientsafety.org

7.7. Health Care ChoicesHealth Care Choices

www.healthcarechoices.orgwww.healthcarechoices.org

8.8. Health GradesHealth Grades

www.healthgrades.comwww.healthgrades.com

9.9. Institute for Healthcare ImprovementInstitute for Healthcare Improvement

www.ihi.org/ihiwww.ihi.org/ihi

10.10. P.U.L.S.E. (Persons United Limiting P.U.L.S.E. (Persons United Limiting SubstandardsSubstandards and Errors in Healthcare)and Errors in Healthcare)

www.pulseamerica.orgwww.pulseamerica.org

11.11. Partnership for Patient Safety (P4PS)Partnership for Patient Safety (P4PS)

www.p4ps.orgwww.p4ps.org

12.12. Patient Patient AdvocateAdvocate FoundationFoundation

National Coordinating Council for Medication Error National Coordinating Council for Medication Error Reporting and PreventionReporting and Prevention

http://http://www.nccmerp.org/consumerInfo.htmwww.nccmerp.org/consumerInfo.htmll

INTERNET RESOURCES FOR DRUG INTERACTIONSINTERNET RESOURCES FOR DRUG INTERACTIONS

�� http://medicine.iupui.edu/clinpharm/DDIs/clinicalTable.asphttp://medicine.iupui.edu/clinpharm/DDIs/clinicalTable.asp ChartChart

�� www.arizonacert.orgwww.arizonacert.org Drug interactionsDrug interactions

�� www.drugwww.drug--interactions.cominteractions.com P450 mediated drug interactionsP450 mediated drug interactions

�� www.torsades.orgwww.torsades.org Drug induced Drug induced arythymiasarythymias

�� www.penncert.orgwww.penncert.org AntibioticsAntibiotics

�� www.deri.duke.edu/research/fields/certs.htmlwww.deri.duke.edu/research/fields/certs.html Cardiovascular MedsCardiovascular Meds

�� www.ascpt.orgwww.ascpt.org Clinical PharmacologyClinical Pharmacology

�� www.epocrates.comwww.epocrates.com Smart Phone accessible data baseSmart Phone accessible data base

Internet Sources for Pharmaceutical Information:Internet Sources for Pharmaceutical Information:

�� www.drugs.comwww.drugs.com

�� www.nlm.nih.gov/medlineplus/drugwww.nlm.nih.gov/medlineplus/druginformationinformation

�� www.rxlist.comwww.rxlist.com

�� www.webmd.comwww.webmd.com//drugsdrugs

�� www.fda.govwww.fda.gov/Drugs /Drugs

�� www.medicinenet.comwww.medicinenet.com//medicationsmedications

�� www.rxlist.com/pillwww.rxlist.com/pill--identificationidentification--tool/article.htmtool/article.htm

�� www.drugwatch.comwww.drugwatch.com

Physician / Hospital Records to Obtain:Physician / Hospital Records to Obtain:

MD Office chartMD Office chart

�� Pt intake questionnairePt intake questionnaire

�� Current Medication ListCurrent Medication List

�� List of allergies, drug reactionsList of allergies, drug reactions

�� Medication refill sheet, ordersMedication refill sheet, orders

�� Medication administration recordsMedication administration records

�� Pharmacy refill requestsPharmacy refill requests

�� Out patient visit MD, NP, RN notesOut patient visit MD, NP, RN notes

�� List of Medication samples given PTList of Medication samples given PT

�� Previous MD office chartsPrevious MD office charts

�� Telephone, email communications with Telephone, email communications with patient or familypatient or family

�� All EMR (Electronic Medical Records) All EMR (Electronic Medical Records)

Hospital Records, EMR (electronic) Hospital Records, EMR (electronic) ::

�� Pt registration formPt registration form

�� Admitting History & PhysicalAdmitting History & Physical

�� MD OrdersMD Orders

�� MD Progress notesMD Progress notes

�� Consultation ReportsConsultation Reports

�� Operative NotesOperative Notes

�� IntraIntra--operative nursing notesoperative nursing notes

�� Anesthesia RecordAnesthesia Record

�� PACU RecordsPACU Records

�� Medication Administration ReportsMedication Administration Reports

�� Nursing GraphicNursing Graphic

�� Laboratory ReportsLaboratory Reports

�� Hospital pharmacy recordsHospital pharmacy records

�� Discharge NotesDischarge Notes

�� Discharge InstructionsDischarge Instructions

�� All All BilllingsBilllings for medications, devices, etc.for medications, devices, etc.

�� All EMR recordsAll EMR records

Pharmacy Records to ObtainPharmacy Records to Obtain::

�� Physician / MD Prescriptions (Physician / MD Prescriptions (RXRX’’ss) )

�� Handwritten / hard copyHandwritten / hard copy

�� FaxFax’’dd prescription ordersprescription orders

�� Email, EMR prescriptionsEmail, EMR prescriptions

�� All medication refill ordersAll medication refill orders

�� Telephone log of communications with Telephone log of communications with

prescribing MD re any med Rxprescribing MD re any med Rx

�� Medications ProvidedMedications Provided

�� All hard copy recordsAll hard copy records

�� All computer / EMR recordsAll computer / EMR records

�� Records of all drug warnings, instructions, Records of all drug warnings, instructions,

�� Pharmacist advice / warnings to PtPharmacist advice / warnings to Pt

�� All billings to Pt , Medicare or Health Insurance All billings to Pt , Medicare or Health Insurance company for medicationscompany for medications

�� Drug Interaction SearchesDrug Interaction Searches

�� All records of any searches for possibleAll records of any searches for possible

drug interaction with other Pt medsdrug interaction with other Pt meds

�� Records of Notice to Records of Notice to RxRx’’inging MD or Pt of any possible MD or Pt of any possible drug interactionsdrug interactions

�� Patient Communications / warningsPatient Communications / warnings�� Log of Telephone calls, communicationsLog of Telephone calls, communications

with patient, family member, or SNF staffwith patient, family member, or SNF staff

�� Copy of all Instruction / drug detail sheets Copy of all Instruction / drug detail sheets given to patient with any medicationgiven to patient with any medication

�� All Docs re Patient Medication All Docs re Patient Medication Reaction(sReaction(s))�� Notes re Pt reports of reactionNotes re Pt reports of reaction

�� EMR / Computer recordsEMR / Computer records

�� SNF records / reports of Med ReactionsSNF records / reports of Med Reactions

�� Billing Records to:Billing Records to:�� Directly to PatientDirectly to Patient

�� Medicare / MedicaidMedicare / Medicaid�� Private Health PlanPrivate Health Plan

�� Other 3pr party payer (family)Other 3pr party payer (family)