Download Systems Analysis, Causes of Medication Errors, and Error

Systems Analysis,
Causes of Medication Errors,
and
Error-Prone Abbreviations
Learning Objectives
• Describe the systems factors that play a
major role in medication errors
• Discuss the proximal causes of medication
errors
• Identify error-prone abbreviations and ways
to improve communication of ambiguous
medication orders
Systems, Not People
• Medication errors are property of the
system as a whole rather than results of
the acts or omissions by the people in the
system
• Performance improvement requires
changing the system, not changing the
people
– Practitioners are sometimes held to an
unattainable standard—perfection
Perspective
• Accepting a goal of a 99.9% success rate,
we’d have:
–
–
–
–
2 million documents lost every year by the IRS
A major plane crash every 3 days
16,000 items lost every hour in the mail
37,000 errors every hour by automated teller
machines
– 107 erroneous medical procedures performed
every day
Proximal Causes of
Medication Errors
• Lack of drug knowledge
• Lack of patient
information
• Rule violations
• Slips and memory
lapses
• Transcription errors
• Faulty drug identity
checking
• Faulty interaction with
other services
Leape LL. JAMA 1995;274:35–43.
• Faulty dose checking
• Infusion pump and
parenteral delivery
problems
• Inadequate patient
monitoring
• Drug stocking and
delivery problems
• Preparation errors
• Lack of standardization
Distribution of Medication
Errors by Proximal Cause
Lack of Drug
Knowledge
22%
Lack of Patient
Information
14%
Rule Violations
10%
Slips/Memory
Lapses
9%
Transcription
Errors
9%
0%
5%
Leape LL. JAMA 1995;274:35–43.
10%
15%
20%
25%
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
Causes of Errors Based on
Key System Elements
•
•
•
•
Lack of information about the patient
Lack of information about the drug
Communication and teamwork failure
Unclear, absent, or look-alike drug labels
and packages, and confusing or look-alike
or sound-alike drug names
• Unsafe drug standardization, storage, and
distribution
Causes of Errors Based on
Key System Elements (continued)
• Nonstandard, flawed, or unsafe medication
delivery devices
• Environmental factors and staffing patterns
that do not support safety
• Inadequate staff orientation, ongoing
education, supervision, and competency
validation
Causes of Errors Based on
Key System Elements (continued)
• Inadequate patient education about
medications and medication errors
• Lack of a supportive culture of safety,
failure to learn from mistakes, and failed or
absent error-reduction strategies, such as
redundancies
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
Patient Information
• 18% of serious preventable adverse drug
events (ADEs) attributable to insufficient
information before prescribing, dispensing,
and administering
• 29% of prescribing errors alone attributable
to a lack of patient information
Patient Information
• Lack of critical patient information
–
–
–
–
–
–
Current laboratory values
Height, weight
Diagnoses
Pregnancy, breastfeeding
Allergies
Other drug therapies
• Lack of interface between laboratory and
pharmacy systems
• Medication reconciliation
Patient Information
• Ideally, essential information is obtained,
readily available in useful form, and
considered when prescribing, dispensing,
and administering medications
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
Drug Information
• 35% of preventable ADEs attributable to
inadequate dissemination of drug information
• One in six ADEs caused by a combination of:
– Insufficient knowledge of drug doses
– Miscalculations
– Incorrect expression of measurement or drug
concentration
Drug Information
•
•
•
•
Lack of accessible or up-to-date references
Lack of a tightly controlled formulary
Failure to use standardized drug protocols
Computer systems that fail to detect unsafe
orders
• Lack of clinical pharmacists in patient care
areas
• Handwritten medication administration
records
Drug Information
• Ideally, essential drug information is
readily available in useful form to those
ordering, dispensing, and administering
medications
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
Communication of Drug
Information
• Barriers that lead to ineffective communication
dynamics
• Unclear order communication
– Ambiguous or incomplete orders
• Illegible handwriting
• Look-alike and sound-alike drug names
• Verbal orders misspoken or misheard
More Types of Failed
Communication
• Zeroes and decimal points
– Always use a “leading zero” (a zero before the
decimal point)
– Never use a “trailing zero” (a whole number followed
by a decimal point and a zero)
• Use of apothecary system instead of metric
system
• Poor design of computer-generated medication
administration records
• Dangerous abbreviations and dose designations
Misinterpreted Physician’s
Prescriptions
• Study showed that medication errors
consequential to misinterpreted
physician’s prescriptions were the
second most prevalent and expensive
claims listed on 90,000 malpractice
claims filed over a 7-year period
Avoid Dangerous Abbreviations
•
•
•
•
Letter “U” for unit
“QD” or “qd” for daily
“QOD” or “q.o.d.” for every other day
IU (International Unit) may be mistaken for
IV (intravenous)
Look-Alike and Sound-Alike
Drug Names
Lamisil
Lamictal
Taxol
Taxotere
Vincristine
Vinblastine
Amrinone
Amiodarone
Ritonavir
Retrovir
Communication
• Ideally, methods of communicating drug
orders and other drug information are
standardized and automated to minimize
the risk of error
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
Environmental factors and staffing patterns
Staff competency and education
Patient education
Quality processes and risk management
Look-Alike Packaging
Sound-Alike Drug Names
Drug Labels and Packaging
• Ideally, strategies are undertaken to
minimize the possibility of errors with
products that have similar or confusing
labels, packages, or drug names
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
Environmental factors and staffing patterns
Staff competency and education
Patient education
Quality processes and risk management
Drug Distribution Practices
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•
•
•
•
•
Unit-dose system
Floor stock
Computer-generated labels
Automated dispensing equipment
Drug storage
Pharmacy access after hours
Drug Standardization,
Storage, and Distribution
• Ideally, intravenous solutions, drug
concentrations, and administration times
are standardized whenever possible
• Unit-based floor stock is restricted
Drug Standardization,
Storage, and Distribution
• Medications should be provided to patient
care units in a safe and secure manner
and available for administration within a
time frame that meets essential patient
needs
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
Environmental factors and staffing patterns
Staff competency and education
Patient education
Quality processes and risk management
Problems Related to
Drugs and Drug Devices
• Labeling and packaging
• Automated compounders
• Infusion pumps
Medication Delivery Devices
• Ideally, the potential for human error is
mitigated through careful procurement,
maintenance, use, and standardization of
devices used to prepare and deliver
medications
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
Problems With Environmental
Factors and Staffing Patterns
• Lack of space, crowded and disorganized
storage
• Poor lighting, excessive noise
• High patient acuity
• Deficient staffing, excessive workloads
Environmental Factors and
Staffing Patterns
• Ideally, medications are prescribed,
transcribed, prepared, and administered in
a physical environment that offers
adequate space and lighting and allows
practitioners to remain focused on
medication use
Environmental Factors and
Staffing Patterns
• The complement of qualified, well-rested
practitioners matches the clinical workload
without compromising patient safety
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
7. Environmental factors and staffing patterns
8. Staff competency and education
9. Patient education
10. Quality processes and risk management
Staff Competency and
Education
• Ideally, practitioners receive sufficient
orientation to medication use and
undergo baseline and annual
competency evaluation of knowledge
and skills related to safe medication
practices
Staff Competency and
Education
• Practitioners involved in medication use
are provided with ongoing education
about medication error prevention and
the safe use of drugs that have the
greatest potential to cause harm if
misused
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
Environmental factors and staffing patterns
Staff competency and education
Patient education
Quality processes and risk management
Patient Education
• Problems
– Failure to adequately educate patients
– Lack of pharmacist involvement in direct
patient education
– Failure to provide patients with
understandable written instructions
– Lack of involving patients in check systems
– Not listening to patients when they express a
concern or question their therapy
Patient Education
• Inform patient of drug names, purpose,
dose, side effects, and management
methods
• Suggest readings for patient
• Inform patient about right to ask questions
and expect answers
• Listen to what patient is saying and
provide follow-up!
Patient Education
• Ideally, patients are included as active
partners in their care through education
about their medications and ways to avert
errors
10 Key Elements of the
Medication System
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient information
Drug information
Communication related to medications
Drug labeling, packaging, and nomenclature
Drug standardization, storage, and distribution
Medication delivery device acquisition, use, and
monitoring
Environmental factors and staffing patterns
Staff competency and education
Patient education
Quality processes and risk management
Culture Change
• Provide leadership
• Design job to:
– Avoid reliance on memory
– Promote simplification and standardization
• Promote effective team functioning
• Anticipate the unexpected
– Design for recovery
• Create a learning environment
Quality Processes
• A nonpunitive, system-based approach to
error reduction is in place and supported by
management, senior administration, and
the board of trustees
Accountability in Systems
• A nonpunitive, system-based approach to
error reduction does not diminish
accountability; rather, it redefines
accountability and directs it in a productive
and useful manner
Quality Processes
• Ideally, practitioners are stimulated to detect
and report errors, and interdisciplinary
teams regularly analyze errors that have
occurred within the organization and in
other organizations for the purpose of
redesigning systems to best support safe
practitioner performance
More on the Problem of
Error-Prone Abbreviations,
Symbols, and Dose Designations
Problems With
Medical Notation
• Ambiguous medical notations are one
of the most common and preventable
causes of medication errors
• Drug names, dosage units, and
directions for use should be written
clearly to minimize confusion
Consequences of Using
Error-Prone Abbreviations
• Misinterpretation may lead to mistakes
that result in patient harm
• Start of therapy may be delayed because
of time spent for clarification
Implement “Do Not Use” List
• The Institute for Safe Medication Practices
(ISMP) and the Food and Drug Administration
recommend that ISMP’s list of error-prone
abbreviations be considered whenever medical
information is communicated
• To access the complete list, go to:
www.ismp.org/Tools/errorproneabbreviations.pdf
Consider All Forms
of Communication
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Written orders
Internal communications
Telephone/verbal prescriptions
Computer-generated labels
Labels for drug storage bins
Medication administration records
Preprinted protocols/prescriptions
Pharmacy and prescriber computer order
entry screens
Short List of
Error-Prone Notations
• The following notations comprise The Joint Commission
“Do Not Use” list and should never be used:
Notation
Reason
Instead Use
U
Mistaken for 0, 4, cc
“unit”
IU
Mistaken for IV or 10
“unit”
QD
Mistaken for QID
“daily”
Short List of
Error-Prone Notations
Notation
Reason
Instead Use
QOD
Mistaken for QID, QD
“every other
day”
Trailing zero
(X.0 mg)
Decimal point missed
“X mg”
Naked decimal
point
(.X mg)
Decimal point missed
“0.X mg”
Short List of
Error-Prone Notations
Notation
Reason
Instead Use
MS
Can mean morphine
sulfate or magnesium
sulfate
“morphine sulfate”
MSO4 and
MgSO4
Can be confused
with each other
“morphine sulfate”
or “magnesium
sulfate”
cc
Mistaken for U
“mL”
Short List of
Error-Prone Notations
Notation
Reason
Instead Use
Drug name
abbreviations
(especially those
ending in “l”)
Mistaken for other
drugs or notations
Complete
drug name
> or <
Mistaken as
opposite of intended
“greater than”
or “less than”
μg
Mistaken for mg
“mcg”
Short List of
Error-Prone Notations
Notation
Reason
Instead Use
@
Mistaken for 2
“at”
&
Mistaken for 2
“and”
/
Mistaken for 1
“per” rather
than a slash
mark
+
Mistaken for 4
“and”
Short List of
Error-Prone Notations
Notation
Reason
Instead Use
AD, AS, AU
Mistaken for OD, OS, OU
“right ear,”
“left ear,”
or “each ear”
OD, OS, OU
Mistaken for AD, AS, AU
“right eye,”
“left eye,”
or “each eye”
D/C, dc, d/c
Misinterpreted as
“discontinued” when
followed by list of
medications
“discharge” or
“discontinue”
Other Good Practices to
Avoid Misinterpretation
• Drug name abbreviations can easily be
confused
– Always write out complete drug name
• Apothecary units are unfamiliar to many
practitioners
– Always use metric units
Example of Misinterpreted
Abbreviation
• Intended dose of 4 units in patient history
• Interpreted as 44 units
• “U” should be written out as “unit”
Example of Misinterpreted
Abbreviation
• Intended dose of “.4 mg”
• Interpreted as 4 mg from medication order
• Should be written as “0.4 mg”
Example of Misinterpreted
Abbreviation
• Intended “Potassium chloride QD” in
medication order
• Interpreted as QID
• Should be written as “daily”
Example of Misinterpreted
Abbreviation
• Intended recommendation of “less than 10”
• Interpreted as 40
• Should be written out as “less than” not “<”
Example of High-Risk
Abbreviation Use
• “QD” in advertisement
• Should be written out as “daily”
Example of Error-Prone
Abbreviation in Medical Literature
• “U” in prominent professional journal article
• Should be written out as “unit”
Avoid Error-Prone Abbreviations
Even in Printed Materials
• Expressions may still be confused
• Perpetuates the impression that
abbreviations are acceptable
• Error-prone abbreviations may be copied
into written orders
Recommendations for
Health Care Professionals
• Avoid ambiguous abbreviations in written orders,
computer-generated labels, medication administration
records, storage bins/shelf labels, and preprinted
protocols
• Work with computer software vendors to make changes in
electronic order entry programs
• Provide examples when educating staff on how using
error-prone abbreviations have led to serious patient harm
• Provide staff with ISMP’s list of error-prone abbreviations
• Introduce health care students to the list of error-prone
abbreviations