Systems Analysis, Causes of Medication Errors, and Error-Prone Abbreviations

1. Systems Analysis, Causes of Medication Errors, and Error-Prone Abbreviations

2. 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

3. 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

4. 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

5. 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 Faulty dose checking Infusion pump and parenteral delivery problems Inadequate patient monitoring Drug stocking and delivery problems Preparation errors Lack of standardization Proximal Causes of Medication Errors Leape LL. JAMA 1995;274:35–43.

6. Distribution of Medication Errors by Proximal Cause Leape LL. JAMA 1995;274:35–43.

7. 10 Key Elements of the Medication System • 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

8. 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

9. 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

10. 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

11. 10 Key Elements of the Medication System • 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

12. 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

13. 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

14. Patient Information • Ideally, essential information is obtained, readily available in useful form, and considered when prescribing, dispensing, and administering medications

15. 10 Key Elements of the Medication System • 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

16. 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

17. 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

18. Drug Information • Ideally, essential drug information is readily available in useful form to those ordering, dispensing, and administering medications

19. 10 Key Elements of the Medication System • 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

20. 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

21. 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

22. 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

23. 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)

24. Look-Alike and Sound-Alike Drug Names

25. Communication • Ideally, methods of communicating drug orders and other drug information are standardized and automated to minimize the risk of error

26. 10 Key Elements of the Medication System • 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

27. Look-Alike Packaging Sound-Alike Drug Names

28. 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

29. 10 Key Elements of the Medication System • 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

30. Drug Distribution Practices • Unit-dose system • Floor stock • Computer-generated labels • Automated dispensing equipment • Drug storage • Pharmacy access after hours

31. Drug Standardization, Storage, and Distribution • Ideally, intravenous solutions, drug concentrations, and administration times are standardized whenever possible • Unit-based floor stock is restricted

32. 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

33. 10 Key Elements of the Medication System • 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

34. Problems Related to Drugs and Drug Devices • Labeling and packaging • Automated compounders • Infusion pumps

35. 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

36. 10 Key Elements of the Medication System • 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

37. 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

38. 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

39. Environmental Factors and Staffing Patterns • The complement of qualified, well-rested practitioners matches the clinical workload without compromising patient safety

40. 10 Key Elements of the Medication System • 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

41. 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

42. 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

43. 10 Key Elements of the Medication System • 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

44. 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

45. 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!

46. Patient Education • Ideally, patients are included as active partners in their care through education about their medications and ways to avert errors

47. 10 Key Elements of the Medication System • 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

48. 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

49. Quality Processes • A nonpunitive, system-based approach to error reduction is in place and supported by management, senior administration, and the board of trustees

50. 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