Download Strategies to Reduce Medication Errors

Strategies to Reduce
Medication Errors: Working to
Improve Medication Safety
Prepared by pharmacist Eman Elayeh
Introduction
Almost everyone in the modern world
takes medication at one time or another
 Most of the time medications are
beneficial
 But some occasion they do harmful
effects (side effects) → adverse drug
events, which is inevitable
 But sometimes the harm is caused by an
error in prescribing or dispensing or
taking medication
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Multiple Factors
Since 1992, the Food and Drug
Administration has received nearly 30,000
reports of medication errors.
 These are voluntary reports, so the
number of medication errors that actually
occur is thought to be much higher.
There is no "typical" medication error,
and health professionals, patients, and
their families are all involved. Some
examples:
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Strategies to Reduce Medication Errors
Examples
1. A physician ordered a 260-milligram
preparation of Taxol for a patient, but
the pharmacist prepared 260 milligrams
of Taxotere instead.
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Both are chemotherapy drugs used for different
types of cancer and with different recommended
doses.
The patient died several days later, though the
death couldn't be linked to the error because the
patient was already severely ill.
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Strategies to Reduce Medication Errors
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Examples
2. An older patient with rheumatoid arthritis
died after receiving an overdose of
methotrexate--a 10-milligram daily dose of
the drug rather than the intended 10milligram weekly dose. Some dosing mix-ups
have occurred because daily dosing of
methotrexate is typically used to treat
people with cancer, while low weekly doses
of the drug have been prescribed for other
conditions, such as arthritis, asthma, and
inflammatory bowel disease.
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Strategies to Reduce Medication Errors
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One patient died because 20 units of insulin was
abbreviated as "20 U," but the "U" was mistaken
for a "zero." As a result, a dose of 200 units of
insulin was accidentally injected.
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A man died after his wife mistakenly applied six
transdermal patches to his skin at one time. The
multiple patches delivered an overdose of the
narcotic pain medicine fentanyl through his skin.
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A patient developed a fatal hemorrhage when
given another patient's prescription for the blood
thinner warfarin.
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Definitions and terminology
Preventable ADE” is harm caused by the use of a
drug as a result of an error (e.g., patient given a
normal dose of drug but the drug was
contraindicated in this patient). These events
warrant examination by the provider to
determine why it happened.
 “Non-Preventable ADE” is drug-induced harm
occurring with appropriate use of medication
(e.g., anaphylaxis from penicillin in a patient and
the patient had no previous history of an allergic
reaction). While these are currently nonpreventable, future studies may reveal ways in
which they can be prevented.
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Scenario/case studies
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Case 1. A 25 kg child with no prior
history of penicillin allergy was
prescribed 250 mg orally of amoxicillin
suspension twice daily (morning and
evening) for 7 days. On the seventh day, the
child inadvertently received a morning dose
of 500 mg instead of 250 mg. The child did
not suffer any negative consequences from
the error
Medication error resulting in no harm
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Scenario/case studies
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Case 2. A 74 year old female with acute
leg pain presented to the emergency
department. She has a history of sleep
apnea.
She has no previous history of opioid use.
Prescriber ordered hydromorphone 2 mg IV.
Patient found unresponsive in respiratory
distress with SP O2 at 70. Naloxone
administered.
A preventable ADE (medicationrelated harm due to error)
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Scenario/case studies
Case 3. A 37 year old patient diagnosed
with an infection for which amoxicillin and
clavulanate potassium is a clinically reasonable
choice. Patient has used amoxicillin and other
antibiotics in past without adverse eff ects.
Prescriber ordered amoxicillin and clavulanate
potassium 500 mg every 12 hours. After taking 3
doses, patient experienced rash and facial swelling.
He was transported to the emergency
department and treated.
 A Non-preventable ADE (medicationrelated harm not due to error)
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Scenario/case studies
Case 4. A 19 year-old male presented with a severe
infection for which treatment with a beta lactam antibiotic
is the drug of choice with no good clinical alternative. In the
past, this patient developed a maculopapular rash to
penicillin. The prescriber, with input from an infectious
disease expert, considered the risk-benefit of using a beta
lactam antibiotic and concluded that it was the best choice in
spite of the previously reported ADE. An order for a beta
lactam antibiotic was initiated with close monitoring of the
patient to quickly identify an allergic reaction if one
manifested.
 On day 3 of therapy, the patient developed a maculopapular
rash and the decision was made to provide symptomatic
treatment of the rash and continue therapy with the beta
lactam antibiotic
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Strategies to Reduce Medication Errors
These and other medication errors reported to
the FDA may stem from poor communication;
misinterpreted handwriting; drug name
confusion; confusing drug labels, labeling, and
packaging; lack of employee knowledge; and lack of
patient understanding about a drug's directions.
 "But it's important to recognize that such errors are
due to multiple factors in a complex medical system,"
says Paul Seligman, M.D., director of the FDA's
Office of Pharmacoepidemiology and Statistical
Science. "In most cases, medication errors can't
be blamed on a single person
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Strategies to Reduce Medication Errors
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A medication error is "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," according
to the National Coordinating Council for
Medication Error Reporting and Prevention.
The council, a group of more than 25
national and international organizations,
including the FDA, examines and evaluates
medication errors and recommends
strategies for error prevention.
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Strategies to Reduce Medication Errors
It is difficult to estimate how often preventable
adverse drug events occur.
 The Institute of Medicine (IOM) report Preventing
Medication Errors estimated that 1.5 million
preventable adverse drug events occur each
year in the United States.
 Another study estimated that 530,000 preventable
adverse drug events occur each year among
outpatient Medicare beneficiaries.
 The annual cost of treating preventable adverse
drug events in Medicare enrollees aged 65 and
older is estimated at $887 million
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Patient information
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Having accurate patient information is the
first priority in medication safety, as it guides
physicians to choose the appropriate
medication, dose, route and frequency.
The following tips can assist your practice
in this area.
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Patient information
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Use patient-specific identifiers.
To help ensure that the right patient receives
the right medication, instruct your staff to
use at least two patient-specific identifiers, such
as the patient's name and date of birth,
when administering medications.
Your practice should also have a “name
alert” process to identify patients with the
same or similar names. This could include a
“name alert” sticker for the chart or a
highlighted name alert for an electronic
health record (EHR).
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Patient information
Verify allergies and reactions.
While this may seem like a “no-brainer,” it is often a
neglected step in the medication process.
 Your practice should have a protocol that requires a
clinical staff member to ask about allergies and reactions
to medications, latex and food (e.g., egg allergies for
some vaccines) before any prescriptions, samples or
office-administered medications are given to the
patient.
 Include the information on the front of a paper chart
(e.g., with an allergy label), on the top of each
progress note page or on the EHR screen.
 When documenting allergies and other medication-related
information, avoid using abbreviations or truncated names
for the medications (e.g., PCN or HCTZ), as these can be
easily misread.
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Patient information
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Highlight critical diagnoses and conditions.
Four important diagnoses have a significant impact on
medication selection, dosing and frequency.
They are diabetes mellitus, kidney disease, liver disease
and psychiatric disease.
Whether you use paper or electronic charts, put a system in
place to highlight these conditions for easy reference when
medications are administered or prescribed.
In addition, when prescribing teratogenic medications to female
patients of childbearing age, document either their negative
pregnancy test results or the education you provided regarding the
need for effective birth control.
It's also important to highlight patients' smoking status and
alcohol consumption, as these factors may affect medication
selection, dosing and frequency.
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Patient information
Update current medications.
 A current medication profile listed in a standard
prominent location on each patient's chart can be
an important safety measure.
 This should be updated at each visit and should
include a reminder to ask not only about
prescription drugs but also over-the-counter
medications, herbal medicines, supplements and
vitamins.
 Structure the medication list to require that the drug,
dose, route, frequency and purpose be recorded for
each medication, herbal or vitamin.
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Update current medications
Indication
DRUG
NAME
Dose
Frequency
Route
Herbs/supplements / vitamins
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Patient information
Standardize height and weight
measurements.
 ISMP recommends that health care professionals record
information in metric units, which are commonly used
in medication labeling and package inserts, as a way to
standardize measurement.
 An easy reference chart for conversion of
inches/pounds to metric measures can be made
available in each exam room, nursing station, etc.
Simplify weights using the following formula: If the
weight is less than 2 kg, carry out weight to two
decimal places; if the weight is 2 kg to 10 kg, carry out
the weight to one decimal place; if the weight is
greater than 10 kg, round to the nearest whole
number.
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Drug information
Maintain drug references. It is unrealistic to expect any
physician can be conversant on the tens of thousands of
prescription and over-the-counter medications on the
market.
 To help decrease risk to patients, make sure that all staff
members who prescribe, dispense, administer or provide patient
education on medications have easy access to current drug
information and other decision support resources.
 Decide on a core set of drug information references that will
be used (e.g., Drug Facts and Comparisons) and update them at
least yearly or whenever a new edition is available. In addition,
consider using personal digital assistants with frequently
updated drug information software (e.g., Epocrates, lexi drug
information).
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Drug information
Identify high-alert meds. Practices should identify
a list of “high-alert” medications that require extra
precautions when administered, prescribed, dispensed or
refilled.
 High-alert medications are those that have a
propensity to cause serious patient harm when used in
error.
 They include warfarin, low-molecular-weight
heparins, insulin and oral agents for diabetes,
opiates and methotrexate.
 ISMP has compiled a list of 14 high-alert
medications as well as a list of 19 high-alert drug
classes/categories, which can be found online
at http://www.ismp.org/Tools/highalertmedications.pdf
.
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High alert medications: Warfarin management
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Lack of dosing guidelines and lack of appropriate monitoring can lead to
serious harm associated with this class of medications.
In a study by Bates et al., anticoagulants accounted for 4% of
preventable ADEs and 10% of potential ADEs.
A literature review by Kanjanarat et al. reports that anticoagulation
therapy is associated with serious and frequent ADEs in both inpatients
and outpatients.
Warfarin and insulins, both of which typically require ongoing
monitoring to prevent overdose or toxicity, caused one in every
seven estimated ADEs treated in emergency departments (14.1%;
95% confidence interval 9.6% to 18.6%); and more than a quarter of
all estimated hospitalizations (871 cases, 95% confidence interval
17.3% to 35.2%).
In the elderly, insulin, warfarin, and digoxin were implicated in one
in every three estimated ADEs treated in emergency departments
(1,592 cases, 33.3%; 95% confidence interval 27.8% to 38.7%); and
41.5% of estimated hospitalizations (646 cases, 95% confidence
interval 32.4% to 50.6%
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High alert medications: Warfarin management
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Warfarin is commonly involved in ADEs for a
number of reasons.
These reasons include the complexity of
dosing and monitoring, lack of patient
adherence, numerous drug interactions, and
dietary interactions that can affect drug activity.
Strategies to improve both the dosing and
monitoring of these high-alert medications
have potential to reduce the associated risks
of bleeding or thromboembolic event
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High alert medications: Warfarin management
 Suggested Changes:
 Because warfarin has
such a narrow therapeutic
index, appropriate dosing and monitoring are critical.
Since ongoing therapy occurs in the ambulatory
setting, it is essential to engage patients by ensuring that
they understand how to take the medication, which other
medications should be avoided, and how to identify
symptoms that indicate harm.
 Include a nutrition consult to educate patients on
warfarin about drug/food interactions.
 Develop a robust communication plan to share
information and to ensure timely follow-up with the
next provider of care when a patient is discharged
from the hospital.
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High alert medications: Warfarin management
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Changes Designed to Ensure Standardization:
Standardize protocols and dosing: Standardize protocols for the
initiation and maintenance of warfarin therapy including Vitamin K
dosing guidelines.
Develop a protocol, based on evidence, to discontinue and restart
warfarin perioperatively.
Develop a protocol, based on evidence, to bridge warfarin therapy
with more rapidly acting anticoagulants such as heparin and
LMWH.
Make information available; for example, improve access to lab
results and/or use of point-of care testing in order to determine
doses.
Initiate patient self-testing of their INR and self-adjustment of their
doses.
Ensure appropriate monitoring, patient education, follow-up, and
dose management through a centralized anticoagulation service.
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Drug information
Identify high-alert meds
 Similarly, practices can refer to the Beers list when prescribing
medications for older adults.
 This is a list of 48 individual medications or classes to avoid in
patients over 65 years of age because the risk is unnecessarily
high and safer alternatives exist.
 The Beers list includes daily fluoxetine (Prozac) because
of its long half-life and risk of producing excessive stimulation
to the central nervous system and increasing agitation; nonCOX-selective NSAIDs because of their potential to
produce gastrointestinal bleeding, renal failure, high blood
pressure and heart failure; muscle relaxants because they
are poorly tolerated by the elderly and cause anticholinergic
adverse effects, sedation and weakness; and large doses of
short-acting benzodiazepines (Ativan, Xanax, etc.) because
seniors are especially sensitive to them.
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Drug information
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Communication
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Share information. Practices must
promote an “equal team member” concept
where communication flows in all directions.
This encourages all physicians and staff to be
vigilant and to detect and act on potential
error signals, rather than dismissing them.
Physicians can model this behavior simply by
asking their nurses, medical assistants and
others for input and by sharing information
with other team members on a regular basis.
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Drug information
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Improve your handwriting. A 1979 study
estimated that one-third of physicians'
handwriting was illegible.
Presumably little has changed over the years.
To ensure that your orders and
prescriptions are legible, try printing rather
than using cursive, sit rather than stand when
writing and work in what safety experts describe
as a “sterile cockpit” (a quiet area for writing).
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Drug information
Avoid problematic abbreviations.
 The FDA and ISMP in July 2006 embarked on a
joint campaign to eliminate the use of potentially
confusing abbreviations, symbols and dose
designations in various forms of medical
communication.
 These abbreviations, symbols and dose
designations have proven to be a barrier to
effective communication and have resulted in
significant harm to patients.
 For example, instead of writing “QD,” which is often
misread as QID, it is recommended that health care
professionals spell out the word “daily.”
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Drug information
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Drug information
Be aware of similar drug names. Handwritten
medication prescriptions can be difficult to interpret ,
particularly if they involve medications that have
similar names such as Isordil – Plendil, Celebrex –
Cerebyx, Lamictal – Lamisil, and Zyprexa – Zyrtec –
Zantac. Many, if not all, of these drugs with similar
names carry different indications for use; therefore,
including the indication with the medication can
reduce confusion.
 The prescription pad shown in this article contains
check boxes for common indication categories that
can help communicate the purpose of the medication
being prescribed. For example, if a physician were
prescribing Zyrtec, he or she would check the box
next to “allergic/immunologic.”
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Drug information
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Drug information
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Require that orders be read back.
Orders given verbally, rather than in written form, are
inherently problematic because of different dialects and
accents, misinterpretations of names and strengths, etc.
The key to a safe process is using “read back.” The staff member
should record the order directly onto the prescription pad/order
sheet/computer as the prescriber is relaying it and then should
read back the information to the prescriber.
The prescriber should request the read back if it is not
offered. During this process, spell the drug name and strength of
the medication.
For example, errors have been reported when the number 15
has been misinterpreted as 50. Always say “one five” for 15 or
“five zero” for 50.
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Labeling and storage
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Separate problematic drugs.
Do not store drugs with look-alike names or similar packaging in close
proximity to each other in the medication storage area, exam medication
storage area, exam rooms or sample closet.
Alphabetized drug storage can cause inadvertent mix-ups.
In addition, segregate any “high-alert” medications that may be used in
the practice (e.g., sedating agents or anesthetics).
Separate and use auxiliary labels for different vaccines, tuberculin
purified protein derivatives (PPD) and other injectable products
that may be confused.
ISMP has reported on several mix-ups with PPD being given in
place of vaccines and vice versa.
Separate external solutions, non-drug items, testing solutions, reagents
and chemicals from internal products.
External products such as benzoin and podophyllin should be labeled
“for external use only.” Hemoccult developers and glucose monitoring
chemicals have been mistakenly used as eye drops.
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Sound a like medications
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Sound a like medications
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See error prone abbreviations
document
 See sound a like medications
document
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