2. Richard Smith, who had a history of kidney disease, had been
admitted to the ICU after a dialysis session where he
experienced severe shortness of breath. The next day, July 30,
2010, he complained of an upset stomach, so the doctor
prescribed the antacid.
The day his daughter came by to visit that morning, and found
his dad "unconscious, unresponsive and on a respirator.“
"The nurse said my dad had coded. I said, 'He coded? When did
that happen?‘”
The doctor told him, "I'm sorry to have to tell you this but the
nurse administered the wrong medication and sent your dad into
respiratory arrest.“
"He said the packaging looked the same and he grabbed the
wrong package,“
The nurse is wrongly given pancuronium instead of antacid.
UPSET STOMACH TO CODE RED
4. MEDICATION ERROR - DEFINITION
“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.
National Coordinating Council for Medication
Error Reporting and Prevention (NCCMERP, US)
5. TO ERR IS HUMAN:
BUILDING A SAFER HEALTH SYSTEM
6. Healthcare is nearly
10 years behind other
industries in its efforts to
reduce errors.
Michael A. Jackson, BS Pharm, RPh
Wesley G. Reines, PharmD
7. “MEDICATION ERROR :
SIMPLE MISTAKE
CAN BE LETHAL”
Medication Safety Is Everyone’s Responsibilities
“PLEASE DO NO HARM”
8. MEDICATION ERROR:
WHY THE CONCERN?
The impact of medication safety incidents on patient outcomes
includes increased length of stay, disability and mortality
( V i n c e n t e t a l . , 2 0 0 1 , U K )
Medication errors are estimated to account for at least 7,000 deaths
in the United States alone every year.
Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of
Medicine; 1999, p. 1 .
Over 770,000 patients are estimated to be injured because of
medication errors every year.
A g e n c y f o r H e a l t h R e s e a r c h a n d Q u a l i t y , 2 0 0 1
At least 1 death occurs per day and 1.3 million people are injured
each year due to medication errors.
Food and Drug Administ rat ion (FDA), US
Medication error is one of the most common causes of unintentional
harm in Australia which results in an estimated 80,000 hospital
admissions every year
( S e n a t o r K a y P a t t e r s o n , F e d e r a l M i n i s t e r f o r H e a l t h a n d A g e i n g A u s t r a l i a , 9 S e p t e m b e r 2 0 0 3 )
9. MEDICATION ERROR:
WHY THE CONCERN?
Medication errors occur in nearly 1 out of every 5 doses given to
patients in the typical hospital.
( R e f e r e n c e : B a r k e r K N , F l y n n E A , P e p p e r G A , P h D , B a t e s D W , M i k e a l R L . M e d i c a t i o n e r r o r s o b s e r v e d i n 3 6 h e a l t h c a r e f a c i l i t i e s . A r c h
I n t e r n M e d 2 0 0 2 ; 1 6 2 : 1 8 9 7 - 1 9 0 3 . )
One 5-year study showed that the most common types of medication
errors were a wrong dose, a wrong drug or a wrong route of
administration.
( R e f e r e n c e : P h i l l i p s J , B e a m S , B r i n k e r A , H o l q u i s t C , H o n i g P , L e e L Y , P a m e r C . R e t r o s p e c t i v e a n a l y s i s o f m o r t a l i t i e s a s s o c i a t e d w i t h
m e d i c a t i o n e r r o r s . A m J H e a l t h S y s t P h a r m . O c t 2 0 0 1 . 5 8 ( 1 9 ) ; 1 8 3 5 - 4 1 )
Adverse medication events have been reported and are estimated to
occur at a rate of around 5% for admissions and discharges from the
typical hospital.
( R e f e r e n c e : C l a s s e n D C , P e s t o n i k S L , E v a n s R S , L l o y d J F , B u r k e J P . A d v e r s e d r u g e v e n t s i n h o s p i t a l i z e d p a t i e n t s . J A M A 1 9 9 7 ; 2 7 7 : 3 0 1 -
3 0 6 . L a z a r o u J , P o m e r a n z B H , C o r e y P N . I n c i d e n c e o f a d v e r s e d r u g r e a c t i o n i n h o s p i t a l i z e d p a t i e n t s . J A M A 1 9 9 8 ; 2 7 9 : 1 2 0 0 - 1 2 0 5 . )
Several studies point to more than 50% of potential and serious
adverse events being associated with injectable medications.
(R e f e r e n c e : K a u s h a l R , B a t e s D W , L a n d r i g a n C , e t a l . M e d i c a t i o n e r r o r s a n d a d v e r s e d r u g e v e n t s i n p e d i a t r i c i n p a t i e n t s . J A M A 2 0 0 1 ;
2 8 5 : 2 1 1 4 - 2 1 2 0 . T h o m a s E J , B r e n n a n T A . I n c i d e n c e a n d t y p e s o f p r e v e n t a b l e a d v e r s e e v e n t s i n e l d e r l y p a t i e n t s : p o p u l a t i o n b a s e d r e v i e w
o f m e d i c a l r e c o r d s . B M F 2 0 0 0 ; 3 2 0 : 7 4 1 - 7 4 4 . )
10. MEDICATION ERROR:
WHY THE CONCERN?
The extra medical costs of treating drug-related
injuries occurring in hospitals alone conservatively
amount to $3.5 billion a year. This estimate does not
take into account lost wages and productivity or
additional healthcare costs
" P r e v e n t i n g M e d i c a t i o n E r r o r s : Q u a l i t y C h a s m S e r i e s ” , I O M R e p o r t , J u l y 2 0 0 6
IOM issued a report on the prevalence of medication
errors in the United States in which at least 1.5 million
Americans are injured every year by medication errors.
13. WHERE CAN MEDICATION ERROR OCCUR?
Medication error 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”
15. Prescribing Transcribing Dispensing Administering
Medication Management Processes
Errors
• Wrong Dose
• Wrong Drug
• Wrong Route/Form
• Allergy
• Drug Interaction
• Wrong Dose
• Wrong Drug
• Wrong Route
• Wrong Time
• Wrong Patient
• Wrong Dose
• Wrong Drug
• Wrong Route
• Wrong Time
• Wrong Patient
• Incorrect Labelling
• Primary Catch for
allergy, drug
interaction
• Wrong Dose
• Wrong Drug
• Wrong Route
• Wrong Time/ Omitted
• Wrong Patient
• Incorrect Labelling
16. MEDICATION SAFETY IS EVERYONE’S
RESPONSIBILITIES
The Pharmaceutical Services Division has always placed
emphasis on medication safety and its strategies are in line with
those of the Patient Safety Council of Malaysia
Strategies to Improve Medication Safety
Reporting & Learning Dissemination of
Information
Guidelines
Education &
Empowerment
18. MEDICATION ERROR REPORTS
Current medication error are reported to:
United States Pharmacopeia
ISMP
Medwatch reports
Manufacturer reports
UK : National Reporting and Learning System (NRLS), National
Patient Safety Agency (NPSA)
Australia : NSW Health Incident Information Management
System(IIMS), Queensland Health Clinical Incident Information
System (PRIME CI) in Queensland
Malaysia : MERS
20. MEDICATION ERROR (ME) REPORTING
SYSTEM (MERS)
Purpose:
a) To obtain information on the occurrence
of medication errors
b) To maintain a database on medication
errors
c) To analyse the report
d) To propose remedial actions and monitor
the situations
e) To minimize the reoccurrence of such
errors
21. NUMBER OF ME REPORTS RECEIVED BY
YEAR
2572
4120
5003
6011
8422
16897
43025
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
24. CONTRIBUTING FACTORS OF ME
12003,
48%
8759,
35%
3066,
12%
1106,
5%
2014
Staff Factors Work Environment
Task & Technology Medication Related
25. Contributing Factors No of Reports Total
Medication
Related
Look alike medication 317
1106
Look alike packaging 337
Sound alike medication 452
Staff Factors
Distraction 3455
12003
Inadequate knowledge 2369
Inexperienced personnel 6179
Task &
Technology
Failure to adhere to work procedure 1647
3066
Illegible prescription 646
Incorrect computer entry 101
Patient information/record/ unavailable/
inaccurate 507
Use of abbreviations 165
Work & Environment
Heavy workload 2566
8759
Peak hour 5492
Stock arrangements/ storage problem 260
Wrong labeling/ instruction on dispensing
envelope or bottle/ container 441
27. ERROR-PRONE ABBREVIATION
Abbreviation Intended meaning Common Error
U Units
Mistaken as a zero or a four (4) resulting in overdose.
Also mistaken for "cc" (cubic centimeters) when
poorly written.
µg Micrograms
Mistaken for "mg" (milligrams) resulting in an
overdose.
Q.D.
Latin abbreviation for
every day
The period after the "Q" has sometimes been
mistaken for an " I, " and the drug has been given
"QID" (four times daily) rather than daily.
Q.O.D.
Latin abbreviation for
every other day
Misinterpreted as "QD" (daily) or "QID" (four times
daily). If the "O" is poorly written, it looks like a period
or "I."
28. ERROR-PRONE ABBREVIATION
Abbreviation Intended meaning Common Error
SC or SQ Subcutaneous
Mistaken as "SL" (sublingual) when poorly
written.
D/C
Discharge; also
discontinue
Patient's medications have been prematurely
discontinued when D/C, (intended to mean
"discharge") was misinterpreted as "discontinue,"
because it was followed by a list of drugs.
IU International Unit Mistaken as IV (intravenous) or 10(ten)
29. MMF – MTF
HCT – HCTZ – HCQ
CBZ – CPZ
IVIg vs Human Albumin
ERROR-PRONE ABBREVIATION
30. HOW TO PREVENT ERROR?
Use generic names for drug. Avoid trade names.
Avoid using abbreviations
Write clear instructions
Daonil Glibenclamide
X √
MTF Metformin
X √
Gutt. CMC BD Gutt. CMC 2 drops RE BD
X √
31. HOW TO PREVENT ERROR?
Use leading zero before decimal point
Avoid trailing zero after decimal point
Avoid verbal orders
Identify patient drug allergies
.5 mg 0.5 mg
X √
5.0 mg 5 mg
X √
33. LOOK ALIKE SOUND ALIKE MEDICATIONS
(LASA)
Medications that are:
Visually similar in physical
appearance or packaging
Name of the medications that have
spelling similarities
34. Inj. Vitamin K 1mg/ml Inj. Neostigmine Inj. Vitamin K 10mg/ml
36. HOW TO PREVENT ERROR?
Double checking the drug (dispensing/administering)
(Pharmacist) Contacting the prescribers in case of
any clarification regarding the prescription
(DO NOT ASSUME)
Becoming familiar with LASA medications
Separating LASA medications from one another
Using Tall Man Lettering
Installing warning system to staff – Computer alerts
or warnings on stock bottles
42. FENTANYL PATCH - HOW TO CUT
Needs to be cut DIAGONALLY
6 MCG/HR
6 MCG/HR
Only for
6mcg/hr dose
For 12mcg/hr
dose, use
25mcg/hr patch
(cut into half)
12 MCG/HR
12 MCG/HR
43. FENTANYL PATCH - HOW TO ADMINISTER
12 MCG/HR
DOSE HOW TO ADMINISTER
6 MCG/HR
FOR 3 DAYS
½ patch
12mcg/hr
18 MCG/HR
FOR 3 DAYS
½ patch
25mcg/hr
+ ½ patch
12mcg/hr
6mcg/hr
6mcg/hr12mcg/hr
+
44. Guide On Handling Look Alike Sound Alike Medications
45. HIGH ALERT MEDICATIONS (HAMS)
Drugs that bear a heightened risk of causing significant
patient harm when they are used in error.
Although mistakes may or may not be more common
with these drugs, the consequences of an error are
clearly more devastating to patients.
Institute for Safe Medication Practice (ISMP)
46. HIGH ALERT MEDICATIONS (HAMS)
• … those that are most likely to cause
significant harm to the patient, even when used
as intended.
• … those medications with the highest
percentage of, or potential for, medication
errors and/or sentinel events and that carry a
high risk for abuse, errors or other adverse
outcomes.
Institute for Healthcare Improvements (IHI)
The Joint Commission (JCAHO)
53. WHEN A MEDICATION ERROR OCCURS, ORGANIZATION WIDE
SYSTEM WEAKNESSES ARE OFTEN IDENTIFIED IN :
How information is collected and communicated,
How colleagues interact,
How patients and staff are educated,
How the organizational culture and physical
environment are managed,
How staff is provided to carry out patient care
functions,
How staff learns about system errors and their causes,
and
How patients are safeguarded from harm.
54. Patient information
Drug information
Communication related to medications
Drug labelling, packaging & nomenclature
Drug standardization, storage & distribution
Medication delivery device acquisition, use, and monitoring
Environmental factors
Staff competency & education
Patient education
Quality processes & risk management
INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) HAS
LISTED DOWN TEN KEY ELEMENTS THAT HAVE THE GREATEST
INFLUENCE ON MEDICATION USE:
55. CONCLUSION
Medication error is common and is causing preventable
human suffering and financial cost
Remember that using medications to help patients is not a
risk-free activity
Interdisciplinary interactions go a long way toward preventing
errors
Know your responsibilities and work hard to make medication
use safe for your patients
Greetings!
Assalamulaikum
Salam sejantera
Thank you for attending today talk, today I would like to talk about an important issues in patient care. Medication safety in an big issues but somehow smaller subset of medical errors.
During this talk you will heard me using Medication Error, Medical Errors interchangeably.
Lets start our session with two case report. Case No 1 – Mr Smith, who is known case of kidney disease and on regular dialysis. Admitted to ICU after a dialysis session because of SOB. The next day, he complaint stomach upset hence his doctor prescribed antacid. The next day, his daughter came by to visit and found that his dad was unconscious and on a respirator. The nurse in-charged inform that, his dad had a code red. Upon asking the doctor who taking care of his dad – she found that the nurse administered the wrong medication. He said the packaging looked the same and he grabbed the wrong package. The nurse is wrongly given pancuronium which is muscle relaxant instead of antacid.
According to National Coordinating Council for Medication Error Reporting and Prevention, US; Medication error can be defined as any preventable event that 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.
At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.
Healthcare is nearly 10 years behind other industries in its efforts to reduce errors.
According to a publish paper in British Medical Journal 2016 by Makary and Daniel. Medical error is a third leading caused of death after heart disease and cancer which account for 251k death in US.
In Malaysia, we already seen a few case reported in local newspaper. This case become viral on social media. This however, just a gist of unreported medical error/negligence.
What type of errors can occur during this process.
Medication safety is everyone’s responsibilities. Not only for pharmacist – its for all healthcare professional. There is for strategies to improve medication safety as placed by MOH Patient Safety Council of Malaysia.
Reporting and learning from mistake.
Dissemination of information – disseminate what the latest issues in patient safety.
Guidelines – provide guidelines to reduced medication errors.
Education and empowerment – educated all healthcare personal regarding medication errors and empower them to report and discuss about medication safety.
There is ways to prevent errors such as:
Prescribing – electronic prescription – reduced risk of transcribing errors.
Admixture and labeling – prepared by skill pharmacist technician and label to minimize error.
Scanning – bar code scanning to minimized error.
Check data and start – check patient information before serving medication.
Documentation – document all process involved.
This form can be fill by anybody including patient. Not necessary must be fill by pharmacist.
In 2009, there is 2572 case of ME being reported to MERS. This report has double in 2010 and subsequently increased to 16897 cases in 2014. Which shown 8x increment from 2009.
The most common process in which the error occur are during prescribing – manual prescribing. Follow by dispensing and administration.
What are the contributing factors of ME?
Staff factors
New/In-experience.
Lack of training
Lack of empowerment
Careless
Not focus
Work and environment
Small area
Noisy environment.
Medication related
Look a like sound a like
Same medication, different strength.
Task and technology
Not femilar with technology.
In 2014- based on report form MERS. The main contributing factor of ME are staff factor followed by work environment, task and technology and medication related.
Hmmm, medication related which account for 5% are not a big issues compared to others. So we are blaming the medication where our big problem are staff factors.
Staff factor are the main source of ME: Inexperienced personnel/Inadequate knowledge – are we train our staff enough? Did we under-train them? Distraction – did we give them conducive environment to work?
Other main important contributing factor of ME are, sound alike medication. Failure to adhere to work procedure – for example need counter checking – did we properly counterchecking each and everyone? Heavy workload – understaff?. Peak hour when a lot of patient need to be entertained.
So we encourage to write full name rather than sing abbreviation.
Stick to 5B/5R rules.
Always ask patient name before giving medication
Give the right medication
Give the right dose
Using right route at a right time – warfarin give at 6pm. CCRT to give drugs before patient undergoes RT. Give patient insulin 30mins before meals.
Double checking the drug – that why we have check by column in the FISICIEN.
Contact prescriber for any ambiguity
List down the LASA medication – educate staff.
When it happen. It not who are important but why its happen are more important. We are not jugging or blaming who involved but we are more interested on why its happen and how to overcome its.
So when its happen, what you will do? REPORT! Do not hide errors caused latter on it will known eventually.
Some fact about what happen to WHO involved in ME.
So how to reduced harm???
Improve reporting and learning – discussed and learn regarding medication errors.
Improve transfer of medicines and information between care setting – share information regarding patient safety, disseminate new info regarding new product especially change of product and dosage.
Improve implementation of patient safety alerts – drug interaction alrets.