MEDICATION SAFETY

MEDICATION SAFETY
Dr A.Issadeen Deputy Regional
Director of Health Services .
Kalmunai

Definitions
• side-effect: a known effect, other than that
primarily intended, relating to the
pharmacological properties of a medication
– e.g. opiate analgesia often causes nausea
• adverse reaction: unexpected harm arising from
a justified action where the correct process was
followed for the context in which the event
occurred
– e.g. an unexpected allergic reaction in a patient taking
a medication for the first time
• error: failure to carry out a planned action as
intended or application of an incorrect plan
• adverse event: an incident that results in harm to
a patient
WHO: World alliance for patient safety taxonomy

Rationale
• Errors cause more death each year than breast
cancer, motor vehicle accidents & AIDS
• Medical error has been identified as the 3rd
leading cause of death in the US
• Sri Lanka- adverse event reporting system
• medication error is preventable
• Doctors- important role in prevention

Responsible
Nurses
pharmacist
Patients &family
Dispenser

Which patients are most at risk of
medication error?
• patients on multiple medications
• patients with another condition, e.g. renal
impairment, pregnancy
• patients who cannot communicate well
• patients who have more than one doctor
• patients who do not take an active role in their
own medication use
• children and babies (dose calculations required)

Medication errors in Sri Lanka
• Data limited
• lack of reporting systems
• in Sri Lanka in 50% of prescriptions use of
non-standard abbreviations
• Incomplete, absence or incorrect details on
route, dose, frequency and duration was
found in 94%, 70%, 34% and 23%
prescriptions respectively. (sl study)

Sequence of the Medication Use
Selection &
Procuring
Establish
formulary
Prescribing
Assess patient;
determine need
for drug
therapy; select
& order drug
Preparing &
Dispensing
Purchase &
store drug;
review &
confirm order;
distribute to
patient location
Administering
Review
dispensed drug
order; assess
patient &
administer
Monitoring
Assess patient
response to
drug; report
reactions &
errors
Clinician &
administrators
Physician/
prescriber
Pharmacist
Nurse/other
health
professionals
All
practitioners,
plus patient
&/or family
Joint Commission. 1998

Medication errors occur
• Prescribing
• Transcribing
• Supplying/ dispensing
• Preparing
• Administrating
• Monitoring treatment

Prescribing
38% 39%
12% 11%
Transcribing
Dispensing
Administeri
ng
Medication Errors Reporting Program US

Prescribing error
• Dosage –paracetamole /liver filure
• administration route
• History –allergy
• documentation
• It is an incorrect drug selection for a patient.
Such errors can include the dose, strength,
route, quantity, indication, or prescribing
contraindicated drug

Hospital - 1

Hospital- 2

Hospital-3

How can prescribing go wrong?
• inadequate knowledge about drug indications and contraindications
• not considering individual patient factors such as allergies, pregnancy, comorbidities,
other medications
• wrong patient, wrong dose, wrong time, wrong drug, wrong route
• inadequate communication (written, verbal)
• documentation -Illegible, incomplete, ambiguous handwriting
• mathematical error when calculating dosage
• incorrect data entry
• Confusion with the drug name
• Use of verbal order
• Use of abbreviations (e.g. AZT has led to confusion between Zidovudine &
Azathioprine)

Dispensing Errors
• It is an error that occurs at any stage during the dispensing
process
• 75.3% arose from patients receiving either the wrong drug
(43.8%) or the wrong dose (31.5%).
• overdose occurred 13.6% of the time
• death, 11.7%
• These errors include the selection of the wrong
strength/product. This occurs primarily when ≥ 2 drugs
have a similar appearance or similar name (look-alike/sound-a-like
errors)

Look-a-like and sound-a-like
medications
• Celebrex (an anti-inflammatory)
• Cerebryx (an anticonvulsant)
• Celexa (an antidepressant)
• Diclofenac sodium/Dilantin sodium /D sodium

Look-a-like

Dispense

Dispensing Errors…..Examples

Dispensing Errors…..Examples

Dispensing Errors…..Examples
Rx
Keppra (anticonvulsant) 500 mg every 12hours
Dispensed
Kaletra (antiviral)

How can drug administration
go wrong?
• wrong patient
• wrong route
• wrong time
• wrong dose
• wrong drug
• omission, failure to administer
• inadequate documentation
• Storage of similar preparations in similar areas

Ambiguous nomenclature
• Tegretol 100mg
• S/C
• 1.0 mg
• .1 mg
• Tegreto 1100 mg
• S/L
• 10 mg
• 1 mg

Reasons For Medication Errors

Error provoking condition
1. Training and experience
2. Patients & family factors
3. Errors in medical supply
4. Physical and mental health
5. Inadequate procedure
6. Poor communication
7. Poor supervision
8. Heavy work load
9. Staffing/skill mix
10. Unsuitable environment
11. Local working culture
unsafe act and omission
memory lapses
action slip /failure
knowledge and
rule based
mistake
violation
MEDICATION
ADMINISTRATI
ON
ERRORS

HOW TO MINIMIZE ERROR

Recommendations
1. Receives the prescription, verifying the
patient’s name and address.
2. Selects the drug from the shelf, labels the
pack counts the doses, and puts them into
the pack,
3. Pharmacist check. “It’s the pharmacist’s
obligation to check everything: the drug,
strength, dosage, everything up to that
point,”

4. Organized the dispensary
one of our hospital—well
organized dispensary

5. discus the prescribing error with medical officer
and develop the error free prescription
6. develop safety culture among the healthcare
professional
7. develop error reporting system in OPD/wards
and report and learn from errors

8. follow the 5 Rs
• right drug
• right route
• right time
• right dose
• right patient

9.Avoiding ambiguous nomenclature
• avoid trailing zeros
– e.g. write 1 not 1.0
• use leading zeros
– e.g. write 0.1 not .1
• know accepted local terminology
• write neatly, print if necessary

10. checking for allergies
11. documentation
12. use generic names
13. develop checking habits
14. communicate clearly
15. know the medications you prescribe well

15.Know the medication you
prescribe well
• do some homework on every medication you
prescribe
• suggested framework
– pharmacology
– Indications
– Contraindications
– side-effects
– special precautions
– dose and administration
– regimen

16.Use memory aids
• textbooks/BNF
• personal digital assistant
• computer programmes, computerized prescribing
• protocols
• free 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!

17.Develop checking habits
• when prescribing a medication
• when administering medication:
– check for allergies
– check the 5 Rs
• remember computerized systems still require
checking
• always check and it will become a habit!

Develop checking habits
• some useful maxims …
• unlabelled medications belong in the bin
• never administer a medication unless you are
100% sure you know what it is
• practise makes permanent, perfect practice
makes perfect
– so start your checking habits now

18.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

Always remember
“to Err is Human!”