Download SHEET L.12 SLIDE 4(Strategies to reduce medication

SHEET L.12 SLIDE 4(Strategies to reduce medication errors)
March 19, 2017
Practice 2
Sheet Number : 12
Dr. Name : Eman Elayeh
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SHEET L.12 SLIDE 4(Strategies to reduce medication errors)
March 19, 2017
 What's the relationship between medical errors and preventable adverse drug events?
Preventable adverse drug event is harm resulting from a medication error.
 Strategies to prevent medication errors:
I should have an accurate patient information and drug information.
 High alert medications:
All hemolytic drugs are considered high alert medications, whether they were direct thrombin
inhibitors or heparin or unfractionated heparin or thrombolytics such as streptokinase.
 What is so special about high alert medications? And why do we call them that?Do they have higher
medication errors?
No, but if there was a mistake in using them, a catastrophic consequences may happen.
 Depending on the medication, I have certain strategies to reduce the medication errors
Today we'll take about warfarin:
We constantly mention warfarin because it has a high percentage of adverse drug events, and many
medication errors may happen when using warfarin in a wrong way.
 Why errors happen when using warfarin?
In the scheme mentioned before, how do we say we have a medication error?
Either inappropriate selection of the medication, dose, route, frequency, duration, dispensing,
administration or monitoring
For example
if the drug needed monitoring of the INR but we didn't do it and suddenly the patient experienced
hemorrhage , the responsibility will fall on the care providers because they didn't monitor the INR
to know if the patient is stable or not or even if the INR is subtherapeutic.
 One of the ways we can use to prevent the medication errors involving warfarin is using the
Protocol.
SOP: Standard operating procedure
For example
I have a device I want to know how to use it, I can follow its SOP which will give me in details how to
turn it on and off and do maintenance for it.
 Why do errors happen sometimes?
Because we didn't follow the procedure or there wasn't a SOP to follow.
 The problem with warfarin that it has a narrow therapeutic index and a high risk of D-D interactions
or D-food interactions, and its dose has great variations and needs constant monitoring.
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SHEET L.12 SLIDE 4(Strategies to reduce medication errors)
March 19, 2017
So the D-D interactions need monitoring and the D-food interactions need patient education to
prevent them from happening, and the dosing needs following a certain guideline.
 The slide contains an example of guideline protocol
The job of this protocol:
suppose a new physician, nurse or a pharmacist were hired in a warfarin clinic and they don't have
knowledge nor a proper experience about warfarin use, we don't tell them to gain experience by
experimenting on people, we have to have a policy or a protocol which the hospital or the clinic or
the pharmacy follow, so that if we want to initiate warfarin or apply dose adjustment we'll have
something standard to refer to.
 Standardized means like in a protocol it decides the starting dose of warfarin when initiating the
treatment
 Before starting warfarin there should be a lab test or a checklist with the nurse or the physician or
the pharmacist who will deal with warfarin.
 We should pay attention that the initiation dose of must be decided by the physician, while the
monitoring or follow up or dose adjustment can be done later by the nurse or the pharmacist and
this is the ideal situation in a warfarin clinic , this isn't seen in JUH because it's all done by the
physician.
 The purpose of the protocol is to transfer the authority from the physician to the pharmacist, the
physician's only authority is to start the warfarin dose.
 The protocol contains the most important lab tests to be done by the physician, like in warfarin he
has to measure INR at baseline and pregnancy if the patient was a female in child bearing age, also
Hemoglobin, Platelets, ALT and serum creatinine should be done.
 The point is that whoever came to treat the patient we must have a protocol we can refer to, so
that no variations in dose initiation or titration or monitoring happen.
 The protocol states how the physician should start the warfarin dose
For example
To start with 5mg, 10mg or less, and then it shows when to do the monitoring. The same idea of the
charts we took in DVT but here it's a part from the policy.
Policy states the dose initiation and how to titrate and adjust the treatment which neglects sources of
variations
 There are people who graduated from USA,Russia..Etc and they must eventually follow the policy of
the hospital they work in.
 The protocol also contains the main elements to teach the patient, like a checklist of patient
education which includes the most important things for the pharmacist or nurse to highlight when
doing the patient education
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SHEET L.12 SLIDE 4(Strategies to reduce medication errors)
March 19, 2017
 A patient came to the hospital and I never dealt with a patient going into surgery and taking
warfarin, so how do I deal with the warfarin in preoperative period?
 There 2 things to consider:
1- risk of bleeding
2- risk of thromboembolism if he stopped warfarin
 How do I balance between risks and benefits?
If the risk of bleeding was high → discontinue
And to compensate for the risk of thromboembolism there's something called Preoperative
management of warfarin, it's a special protocol which shows how to deal with warfarin in
preoperative period.
 Not every doctor should act his way, it should be standardized
 The protocol guarantees that I'll have standardization for the use of medication, monitoring, dose
adjustment and discontinuation.
 So that's one way to reduce medication errors for high alert medications.
 Not all high alert medications have protocols; warfarin and chemotherapy are examples of the
ones which have protocols.
We should see and read the protocol and understand its contents.
 Other than the high alert medications, we should also know a group of drugs called Beer's drugs
 High alert medications aren't related to age
 There is a group of medications which are considered unsafe for geriatric patients; they're
mentioned in the American geriatric society
 There is something called Beers criteria (named after the doctor who wrote it), it consists of a table
determining the drug that should be avoided in geriatrics and what rationale
For example
It's preferred to avoid anticholinergic drugs in geriatrics.
What are anticholinergic drugs? There are drugs which have an anticholinergic effect and other drugs
which have side effects which are anticholinergics.
 In the slide. There are also alternatives for drugs which are not safe in geriatrics, and it's an article
that talks about alternative medications(because Beers didn't mention the alternatives)
For example
Beers says that first generation antihistamine is not recommended in geriatrics, but what if the
patient got a flu what can I give him instead?
So we have an article which talks about the alternatives to use
 We should know the high alert medications and drugs that aren't safe in geriatrics
 Where can we get the high alert medications?
From ISMP (Institute for safe medication practices)
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SHEET L.12 SLIDE 4(Strategies to reduce medication errors)
March 19, 2017
 The Beers criteria is released by the American geriatric society, the last release was in 2015
 To avoid medication errors we should also improve our hand writing, because not all people have
clear handwritings, we can use printing to avoid the consequences from bad handwritings.
 Error-prone abbreviations (only the ones mentioned by the doctor are required)
 There is a group of abbreviations which are forbidden to use because they can be a source of error,
they are also released by the ISMP which released the high alert medications:
12-
Microgram sign (μg), we're supposed to write it (mcg) because it can be mistakenly read as (mg).
BT which means bedtime, in poor handwriting it could be read as BID which means twice daily.
So we should write it plainly bedtime.
3- cc (cubic centimeter) is also forbidden because with the physician's handwriting it could be read
as two zeros (00) or as (u, units) so it's supposed to be written as ml not cc.
4- D/C which means discontinue or discharge. So if it was meant as discontinue but understood as
discharge then the patient will be discharged too early, and if it was meant as discharge but
understood as discontinue this may create a problem. So we write the word as a whole
(discharge) or (discontinue).
5- IN which means intranasal , but could be read as IM or IV.
6- HS which means half-strength, it could be read as (hs) which means at bedtime. So it should be
written plainly as at bedtime or half-strength.
7- IU which means international units, we don't write IU or U we plainly state it as International.
8- OD or Od which means once daily, some people may read it in Latinas right eye so it should be
written as Once daily or Daily.
9- Per os which means by mouth or orally, but it could be read in Latin as left eye.
10- QD or qd which means everyday, it could be read as (qid) which means 4 times a day.
11- QOD or q.o.d which means every other day, it could be read as QD or qd.
*All these abbreviations are forbidden to use in handwriting and in printing.
12-SC or SQ or Subq which means subcutaneous, SC could be read as SL (sublingual) ,SQ could be
read as (5 every), Subq could be read as (every) so it should be clearly written as subcutaneous
or Subcut.
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SHEET L.12 SLIDE 4(Strategies to reduce medication errors)
March 19, 2017
13- ss which means sliding scale (used in insulin) , it could be read as (55)
14- SSRI which means sliding scale regular insulin, it could be understood as (Selective serotonin
reuptake inhibitors)
*Sliding scale only goes with regular insulin
*Also SSI is forbidden to write because it may be understood as (Strong solution of iodine)
15- U or u which means unit, it could be read as (4).
16- All zeros, for example if I want to write 100000 IU I should put comma's because it's easily misread
17- Trailing zero (zeros added to give some kind of significance), for example: 1.0, 1.00 ...
But there is no need to add them in doses because it could be misread as 10,100
18- Decimal point or leading zero like (0.5 mg), we shouldn't put the decimal point without the zero so
it won't be misread as ( 5 mg)
19- mg and ml must be distant from the numbers
20- some medications ending with (l) such as inderal and tegretol, if the number came right after the
letter (l) it could be read as (1), for example Inderal 40 mg, if they were close it could be read as 140
mg. also Tegretol 300 mg could be read as 1800 mg. so a space should be used between the name
and the dose
21- here are a group of medication's names which have abbreviations we can't use ,such as APAP
(Paracetamol, Acetaminophin)
 HCL (hydrochloride) could be read as pottasium chloride.
 HCT (hydrocortisone) could b read as hydrochlorothiazide.
 HCTZ (hydrochlorothiazide) could be read as hydrocortisone.
 MgSO4 (Mg sulfate) could be read as morphine sulfate (MSO4).
 MTX (methotrexate) could be read as metoxantrone.
*Both are chemotherapeutic agents but from different classes and indications
Generally all medications which abbreviations are forbidden to use should be written as full names.
22- & which means AND, could be read as (2)
@ Which means at, could be read as (2)
 There' another table about sound-alike medications:
Examples: Nidazole-Nizaral, Sinnalax-Nervelax, Neuribion-Neurorubine, Spersadex-Spersallerg,
Lamisil-Lanicata; Xyzal-Xatral, Zelax-Zeldox, Zyrtec-Zyprexa
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SHEET L.12 SLIDE 4(Strategies to reduce medication errors)
March 19, 2017

I should know such medications and know the active ingredient for each of them and their uses
to be able to differentiate between them (active ingredient + Indication)
For example
If a prescription came with Lamisil (Antifungal →Terpenafine) Or Lamicatal (Lamotrigine), the first thing I
should ask about is why did the doctor prescribe this medication?
If the patient said for a fungal infection in my feet then I would know its Lamisil, if he said for the nerves
then I would know its Lamicatal.

Sometimes the drug may be available as tablets only, and the patient came saying he wants a
cream, then I would know which drug of the two is it

So I can differentiate either from the indication or (if it was similar) then from the dosage form,
if we couldn't then we can know from the doses
For example
A drug is available as 10 mg but the required dose was 200 mg then I would know that it isn't this drug
but the other one and so on.

The prescription in the slide was Avendia not Coumodin(warfarin)

One of the things which reduce the errors is the presence of the indication on the prescription
So if the names were similar I can differentiate from the indication

If the patient called the pharmacy or the hospital and asked for a certain medication, I should
ask him to repeat and spell it to minimize errors (high alert medications mustn't be ordered
from the phone)


The errors can be between: fifty and fifteen
So I have to reread the name and spell it to make sure, for example: A V A N D I A
Look-alike medications (The pictures are in the slides)
 It's very important for such drugs not to be stored beside each other so there won't be a source
of error
There are things for external use only (benzoin toxic) so they're put in a place and (for external
use only) should be written on them.
 Look-alike medications should be separated, not on the same shelf.
Fluids and solutions shouldn't be stored with medications, but in a special place away from
them.
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SHEET L.12 SLIDE 4(Strategies to reduce medication errors)
March 19, 2017
،‫ وأعط لالختيار وقتا ً كافيا ً لينضج الكالم‬،‫اختر كالمك قبل أن تتحدّث‬
‫فالكلمات كالثمار تحتاج لوقت كافٍ حتى تنضج‬.
Lana Abu Khadija
Christine Haddadin
Raghad Qamareldeen
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