Home | About PharmaCorner | Guest Book | Advertising | Site Map | Contact us
24 Apr 2017 Welcome visitor
  This section talks about medication safety programs, Strategy, and Self Assessment. 
Search
Login | Register
Pharmacy Ethics
The Calculator
Pharmacy News
Ask The Expert
FAQ´s
Training Programs
Parenteral Medications
Hazardous Medications
Continuing Education
Pharmacy History
Public Education
Important Links
Services


 
Enter your Email address

Home > Hospital Pharmacy > Medication Safety > Medication Errors

Written By: Abier Hamami.RPH.CPHQ

  1. Definitions.
  2. Types of Medication Errors.
  3. Medication Errors Severity.
  4. Medication Errors Reporting.
  5. Recommendations to Prevent Prescribing Errors.
  6. Recommendations to Prevent Dispensing Errors.
  7. Recommendations to Prevent Administering Errors.

Definitions:

The National Coordinating Council for Medication Error Reporting and Prevention NCCMERP defines medication error as "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 professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

Medication Errors are errors in any part of the medication use process (prescribing, transcribing, dispensing, administering, or monitoring) which may or may not result in an adverse outcome.

Types of Medication Errors:

  • Prescribing Error

An error that originated from the written medication order, It Includes order written illegibly or unclear, order written on wrong patient, order written for wrong drug, wrong dose, wrong frequency, and wrong route.

  • Transcribing Error

An Error that originated during transcription of the physician order to the Medication Administration Record MAR. It includes order transcribed to wrong patient, order transcribed for wrong drug, wrong dose, wrong route, wrong schedule.

  • Dispensing Error

An error originated from the point that the drug was prepared in the pharmacy. It includes medication dispensed to wrong patient, wrong drug, wrong dose, wrong route, wrong frequency dispensed.

  • Administering Error

An error originated during the administering process of medication to the patient. It includes medication administered to wrong patient, Wrong drug, wrong dose, wrong route, wrong frequency administered. It also includes errors of omission.

  • Monitoring Error

An error originated from the lack of necessary monitoring. It includes necessary monitoring not ordered, not performed, and not acted upon.

Medication Errors Severity:

Different scaling systems have been used to classify or categorize medication errors severity, some used numerical scales as (Level 0 to Level 6), or alphabetical scales as (A to I), or word scales as (near miss, minor to Death). In all scales the classifications range between no error or potential error to death.

These scales aid in tracking and analyzing medication errors, and their impact on patients.

The following is the NCCMERP Index for Categorizing Medication Errors:

Type

Category

Definition

No Error

A

Circumstances or events that have the capacity to cause error

Error, No Harm

B

An error occurred but the error did not reach the patient (An error of omission does reach the patient)

C

An error occurred that reached the patient but did not cause patient harm*

D

An error occurred that reached the patient and required monitoring* to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm

Error, Harm

E

An error occurred that may have contributed to or resulted in temporary harm to the patient and required Intervention*

F

An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization

G

An error occurred that may have contributed to or resulted in permanent patient harm

H

An error occurred that required intervention necessary to sustain life*

Error, Death

I

An error occurred that may have contributed to or resulted in the patients death

Harm

Impairment of the physical, emotional, or psychological function,or structure of the body and/or pain resulting there from.

Monitoring

To observe or record relevant physiological or psychological signs.on Errors Algorithm

Intervention

May include change in therapy or active medical/surgical treatment.

Intervention Necessary to Sustain Life

Includes cardiovascular and respiratory support (e.g., CPR, defibrillation, intubation, etc.).

Medication Errors Reporting:

Medication errors should be reported regardless of whether the error resulted in an adverse event on the patient. The reporting of all medication errors allows assessment of the medication use process, and identifies opportunities for improvement, so the goal is not only collecting data, but finding ways to prevent future errors.

Reporting medication errors could be mandatory in case of serious injuries or deaths as obliged by law in some states of America, or voluntary as applied in most organizations in the world. There are lots of external voluntary reporting organizations that allow for confidential review and analysis of reported medication errors, as the:

MEDMARX.

Most organizations have been moved from the paper-based reporting systems that usually

do not promote a non-punitive culture with a mechanism for anonymity, and is time consuming, to the web-based anonymous reporting systems that can provide electronic notification of important stakeholders of events, and rapid access to data with statistical analysis. Lots of published articles show electronic reporting had improved the reporting of errors to a great extent.

In general, any reporting form either electronic or paper should be simple and user friendly, and contain the following elements:

  • Patient specific information.

Include patient name, medical number, age, location, and date of occurrence.

  • Medication Specific information.

Include medication class, name (brand, generic), dose, concentration, strength, route, and time.

  • Types of medication errors.

Usually this part will illustrate all types of medication errors (prescribing, transcribing, dispensing, administering, and monitoring) with detailed description and examples on each type, so the reporter can only choose what is appropriate.

  • Medication error severity levels/ patient outcome.

All levels or categories should be clearly defined.

  • Description of the event includes answers to (when, what, and how it happened?).

It should be objective, summarized, and not pinpointing or blaming.

  • Actions taken as informing the related physician or supervisor, and description of any treatment given.
  • Contributing factors or possible causes.

Most of the forms contain a list of predetermined system- based causes as (medication knowledge deficiency, non adherence to policies and procedures, equipment failure, distraction, work overload, use of abbreviation, staffing deficiency, look-alike names or packages, insufficient training )so the reporter could determine.

  • Recommendations to prevent this error to happen again in the future.
  • Information on the reporter which is usually optional and could help in any further needed explanations.

Recommendations to Prevent Prescribing Errors:

1. Review all existing drug therapy before prescribing new drug to eliminate any drug interaction, or duplication.

2. Select the appropriate drug therapy, and always seek information when prescribing drugs for conditions not experienced.

3. Avoid telephone and verbal orders; except in emergency cases in which it is impossible to write the order.

4. All prescriptions must be legible and in plain language. Prescribers, whenever possible should adopt a direct computerized order entry system.

5. Avoid the use of abbreviations. The Institute of Safe Medication Practice ISMP , and the Joint Commission On Accreditation of Health Care Organizations JCAHO have a list of problem prone, and "Do Not Use" abbreviation

6. Prescriptions should always include specific instructions for use, and avoid "As Directed".

7. Prescription orders should specify indication for use (e.g., for cough).

8. Prescribers should include the name, the age, and the weight of the patient.

9. The prescription should include the drug name, strength/ concentration, dosage form, dose, route, frequency, and duration of therapy.

10. The dose should be written in the metric system (e.g. mcg, mg, gm), except for therapies that use standard units such as insulin. Units should be written in full rather than writing an abbreviation such as a U.

11. Use a leading zero for doses less than one (e.g. 0.5 grams NOT .5 grams), and Do Not use trailing zeros after whole number doses (e.g. 5 grams, NOT 5.0 grams).

12. Place adequate space between the drug, dose, and unit of measure (e.g. Inderal 40 mg, NOT Inderal40mg).

13. Use commas for dosing units at or above 1,000(100,000 unit, NOT 100000unit).

14. Do not use a terminal period after the unit of measure (e.g. mg, NOT mg.).

Recommendations to Prevent Dispensing Errors:

1. Check with the prescriber if the order is confusing or illegible.

2. Review the prescription or physician order for drug and dose appropriateness, drug interaction, and duplication of therapy.

3. An independent check by a second pharmacist, or by the same pharmacist for a second time should be used before dispensing the drug to the patient especially with high risk drugs as heparin, insulin, chemotherapeutics. Other methods of checking include the use of automation (e.g. bar coding systems).

4. Labels must be read when selecting the product, when packaging the product, and when returning the product to the shelf or discarding it.

5. Double check any dosage calculation.

6. Dispense medications in ready-to-administer dosage forms when possible.

7. Use auxiliary labels when needed as "Shake Well", "For External Use Only", and "Refrigerate".

8. Deliver medications to patient care areas in a timely manner as approved by the hospital policies, and communicate with the caring nurse in case of any delay.

9. Review returned doses to discover omitted doses or unauthorized drugs.

10. Counsel ambulatory patients on the use of their medications. Counseling should include (indication and direction of the use, side effects, food-drug interactions, storage conditions, expected outcome).

11. Pharmacists should be involved in the preparation and approval of preprinted orders and forms.

12. Product inventory should consider storage of look-alike drugs separated, and not just alphabetically arranged.

13. The dispensing area should be properly designed to eliminate stress, and decrease distraction.

14. Improve staffing to attain reasonable work load.

15. Train and orient pharmacy staff on accepted standards of practice related to accurate dispensing processes with the ultimate goal of medication error reduction.

16. Data on orders clarified should be collected, analyzed, and reported to enhance prescribing practices.

Recommendations to Prevent Administering Errors:

  1. Before administering the drug, nurses should be familiar with the drug indication for use, expected outcome, side effects, drug interactions, storage conditions, and administering technique.
  2. Clarify any order that is incomplete, illegible, prior to administration using an established process for resolving questions.

  1. If transcription of orders is used assure the following elements are double checked: Date of the order, Full name of the drug, Dose form and amount, Administration route, time schedule, Date to start the drug, and Date to stop the drug.

  1. Before administering the drug perform the following checking (6 Rights): the right medication, in the right dose, to the right person, by the right route using the right dosage form, at the right time, with the right documentation.

  1. Nurses administer only medications that are properly labeled and that during the administration process, labels be read three times: when reaching for or preparing the medication, immediately prior to administering the medication, and when discarding the container or replacing it into its storage location.

  1. Medication doses should not be removed from packaging until immediately before administering.

  1. Administer drugs at scheduled times, and document it on the medication administration record.

  1. Discuss the name, purpose and effects of the medication with the patient and/or caregiver, especially upon first time administration and reviewed upon subsequent administrations.

  1. Avoid borrowing medications from other patients in case of missing the dose.

  1. Provide nurses with adequate training regarding medication administration devices, and routinely monitor or verify that users of such devices demonstrate competency regarding the device, it's operation, and it's limitations.

  1. Nurses' medication knowledge and administration competencies should be initially, and then continuously evaluated.

  1. Monitor patients for therapeutic and/or adverse medication effects.

  1. Listen to the patient if he/she questions or refuses to take the drug, and double check the original order.

  1. Environmental factors such as lighting, temperature control, noise-level, occurrence of distractions (e.g., telephone and personal interruptions, performance of unrelated tasks, etc.) should be examined in any medication administration area.

  1. Sufficient staffing and other resources must be provided for the given workload.

  1. The use of integrated automated systems (e.g., direct order entry, computerized medication administration record, bar coding) to facilitate review of prescriptions, increase the accuracy of administration, and reduce transcription errors.

References:

  • ASHP Guidelines on Preventing Medication Errors in Hospitals, Best Practices for Hospital & Health- System Pharmacy, 2005-2006.
  • The Netherlands International Pharmaceutical Federation. Statement of Professional Standards. Medication Errors Associated with Prescribed Medication.
  • Addressing Medication Errors in Hospitals, Ten Tools, California Healthcare Foundation. 2001.
  • Recommendations from the National Coordinating Council for Medication Error Reporting and Prevention (www.nccmerp.org). Accessed Jan 2006
  • The Institute of Safe Medication Practices. (www.ismp.org ).

All Rights Reserved to pharmacorner 2007 - Disclaimer - Contact us