Chapter 12 Medication Safety
Chapter 12 Topics • Medical Errors • Medication Errors • Prescription-Filling Process in Community and Hospital Pharmacy Practice • Medication Error Prevention • Medication Error and Adverse Drug Reaction Reporting Systems
Learning Objectives • Understand the extent and effect of medical errors on patient health and safety • Describe how and to what degree medication errors contribute to medical errors • List examples of medication errors commonly seen in practice settings • Apply a systematic evaluation of opportunities for medication error to a pharmacy practice model • Identify the common medication error–reporting systems available
Medical Errors • Amedical error is any circumstance, action, inaction, or decision related to healthcare that contributes to an unintended health result • Most of what is known about medical errors comes from information collected in the hospital setting • hospital data make up only a part of a much larger picture • most healthcare is administered in the outpatient, office-based, or clinic setting • Medical errors are difficult to define • possible causative circumstances are infinite
Medical Errors • Medical-related lawsuits show the scope of medical errors in the United States • One large government studied only medical errors during hospitalization • 44,000 to 98,000 people in the U.S. die each year as a result of medical errors (greater than the risk of death from accident, diabetes, homicide, or human HIV and AIDS) • multiple sources for potential medical errors exist
Medical Errors • Pharmacy technicians should • be constantly on the “lookout” for possible sources of errors • adopt patient safety–oriented work practices • take steps to protect the safety of patients • become an important barrier against an adverse patient outcome
Discussion What are some examples of medical errors?
Discussion What are some examples of medical errors? Answer: Lab tests drawn at the wrong time (inaccurate results), major surgical errors ending in injury or death
Terms to Remember • medical error
Medication Errors • Amedication error is a medical error in which the source of error or harm includes a medication • Like medical errors • medication errors have no specific definition because the possible causes can be endless • information on the effect of medication errors comes mostly from studies done in the hospital setting • Medication-related deaths are estimated at about 7,000 each year
Medication Errors • Fewer studies of medication errors in community practice exist • an estimated 1.7% of all prescriptions dispensed in a community practice setting contain a medication error (4 of every 250 prescriptions) • Not all medication errors result in harm to a patient • 65% of the medication errors detected had a meaningful effect on the patient’s health
Medication Errors • Measuring results of medication errors • lost lives • disabled patients • time lost from work or school • cost to the healthcare system
Healthcare Professional’s Responsibility • Working in healthcare means making a commitment to “first do no harm” • The profession of pharmacy exists to safeguard the health of the public • Healthcare must focus on treating the patient • to the best possible outcome • by the safest possible means • No “acceptable” level of medication error exists • effect of a potential medication error on the patient cannot be predicted • each step in fulfilling medication orders should be reviewed with a 100% error-free goal
Healthcare Professional’s Responsibility Safety Note The only acceptable level of medication errors is zero.
Healthcare Professional’s Responsibility • Pharmacists are responsible for the accuracy of the medication-filling process • technicians can assist in ensuring safety • Pharmacists and pharmacy technicians can work together to create a net of safety • Proper packaging and instruction on medication use • facilitates correct administration by a patient
Healthcare Professional’s Responsibility • Technicians can identify potential patient sources of medication error • careful listening and observation during a patient or medical staff interaction • notifying the pharmacist • Technicians make a significant contribution to patient safety • constant surveillance for potential sources of medication error
Tips for Reducing Medication Errors • Always keep the prescription and the label together • Know common look-alike and sound-alike drugs • Keep dangerous or high-alert medications in a separate storage area • Always question bad handwriting • Prescriptions/orders should be correctly spelled with drug name, strength, appropriate dosing, quantity or duration of therapy, dose form, and route • Use the metric system
Tips for Reducing Medication Errors • Question uncommon abbreviations • Be aware of insulin mistakes • Keep the work area clean and uncluttered • Verify information • Labels should always be compared with the original prescription by at least two people
Healthcare Professional’s Responsibility Safety Note If information is missing from a medication order, never assume. Obtain the missing information from the prescriber.
Tips for Reducing Medication Errors: Pharmacists • Check prescriptions in a timely manner • Initial all checked prescriptions • Visually check the product in the bottle • Cross-reference prescription information with other validating sources • Encourage documentation of all medication use • Document all clarifications on orders • Maintain open lines of communication with patients, healthcare providers, and caregivers
Tips for Reducing Medication Errors: Technicians • Use the triple-check system • Regularly review work habits • Verify information with the patient or caregiver • Observe and listen • Keep your work area free of clutter
Patient Response • Most patients have the intended therapeutic response expected from the medication • Unique physical and social circumstances make it impossible to predict which • medication errors may result in no substantial harm • may result in death
Physiological Causes of Medication Errors • Each patient has a unique response to medication • genetically unique • speed at which medications are removed from body varies • Even a problem caught and corrected before harm occurs is still considered a medication error
Social Causes of Medication Errors • Outpatients can contribute to medication errors through incorrect administration • Social causes of error include: • failure to follow medication therapy instructions because of cost • noncompliance • failure to receive therapy • misunderstanding instructions (language barriers)
Social Causes of Medication Errors • Patients can contribute to medication errors by • forgetting to take a dose or doses • taking too many doses • dosing at the wrong time • not getting a prescription filled or refilled in a timely manner • not following directions on dose administration • terminating the drug regimen too soon
Social Causes of Medication Errors • Social causes may result in an adverse drug reaction, or a toxic dose • Over 50% of patients on necessary long-term medication are no longer taking their medication after 1 year • All of these social circumstances would be considered medication errors
Categories of Medication Errors • Possible causes of a medication error are numerous • Categorizing errors into types aids in identification and prevention of possible causes • Categories focus on grouping errors under a set of common definitions
Categories of Medication Errors • omission error: a prescribed dose is not given • wrong dose error: a dose is either above or below the correct dose by more than 5% • extra dose error: a patient receives more doses than were prescribed by the physician • wrong dose form error: dose form or formulation that is not the accepted interpretation of the physician order • wrong time error: drug is given 30 minutes or more before or after it was prescribed
Categories of Medication Errors • Errors can be classified by what causes the failure of the desired result • Errors can be categorized within three basic definitions of failure: • human failure • technical failure • organizational failure
Categories of Medication Errors • Human failure is a failure that occurs at an individual level • pulling a medication bottle from the shelf based on memory, without cross-referencing the bottle label with the medication order/prescription • errors made by the patient such as non-compliance to prescribed drug therapy • Technical failureis a failure resulting from location or equipment • incorrect reconstitution of a medication because of a malfunction of a sterile-water dispenser • failure to properly operate automated equipment
Categories of Medication Errors • Organizational failure is a failure because of organizational rules, policies, or procedures • a policy or rule requiring preparing drugs in an inappropriate setting Visit the Veterans Administration (VA) National Center for Patient Safety Web site for a glossary of patient safety terms
Root Cause Analysis of Medication Errors • Root cause analysis is a logical and systematic process used to help identify what, how, and why something happened to prevent reoccurrence • With basic principles of root cause analysis, any person can • examine his or her own work flow to determine the opportunities for potential error • determine what type of failure the potential error may be • create a list of specific potential causes
Root Cause Analysis of Medication Errors • Identifying specific potential causes allows a person to take specific actions to prevent the potential error • Actions taken improve the quality of work being done • Common causes of medication error by handlers and preparers include: • assumption error • selection error • capture error
Root Cause Analysis of Medication Errors • assumption error: an essential piece of information cannot be verified and is guessed or presumed • misreading an abbreviation on a prescription • selection error: two or more options exist, and the wrong option is chosen • using a look-alike or sound-alike drug instead of prescribed drug • capture error: focus on a task is diverted elsewhere and an error goes undetected • something captures the person’s attention, preventing the person from detecting the error or causing an error to be made
Root Cause Analysis of Medication Errors • To prevent capture errors • determine when and where in the prescription-filling process it is safe to allow focus on a task to be diverted • Knowing when and when not to allow interruptions is important in individual safety practices
Root Cause Analysis of Medication Errors Safety Note • Maintaining focused attention when filling prescriptions is important to avoid errors.
Discussion What are some ways to reduce each category of error?
Discussion What are some ways to reduce each category of error? Answer: Assumption errors may be avoided by verifying all information instead of guessing; capture errors may be avoided by reviewing work habits and determining when interruptions are or are not appropriate; selection errors may be avoided by cross-referencing products chosen with the order/prescription and the shelf label.
medication error omission error wrong dose error extra dose error wrong dose form error wrong time error human failure technical failure organizational failure root cause analysis assumption error selection error capture error Terms to Remember
Prescription-Filling Process in Community and Hospital Pharmacy Practice • Review for potential causes of medication error begins with outlining work tasks in a step-by-step manner • Each step in this process can be a • source of medication error • place where pharmacy personnel can correct a medication error
Prescription-Filling Process in Community and Hospital Pharmacy Practice • In the hospital setting medications pass through an extra set of hands—the nurse’s—before reaching the patient • an extra opportunity to prevent medication errors • an additional source of potential medication errors • Each step should be reviewed to determine what information is necessary to complete the step • what resources can be used to verify the information • what errors might result if information is missed or verification is not performed
Prescription-Filling Process in Community and Hospital Pharmacy Practice Safety Note Each person who participates in the filling process has the opportunity to catch and correct a medication error.
Prescription-Filling Process Think of each step in three parts: • information that must be obtained or checked • resources that can be used to verify information • potential medication errors that would result from a failure to obtain or check the necessary information using the appropriate resources
Prescription-Filling Process Step 1: Receive Prescription and Review Patient Profile • Initial check of all key pieces of information is vital • thoughtful and thorough initial review reduces the chances that an unidentified error will continue through the filling process • Legibility: Can you read and understand it? • any unclear information should be clarified before any further action is taken
Prescription-Filling Process Safety Note Careful review of the prescription or order is very important.
Prescription-Filling Process Step 1 • Validity: Is the prescription valid? • requirements may vary from state to state • every technician should be familiar with the definition of valid prescription for the state in which he or she practice • does it contain all the required information to be valid? • a prescription is valid for up to 1 year (less in some cases) from the date of its writing • if not valid, the prescription should not be filled
Prescription-Filling Process Safety Note Outdated prescriptions should not be filled.
Prescription-Filling ProcessStep 1 • Patient information: Is there enough detail to ensure that unique individuals can be pinpointed? • full names, addresses, dates of birth, and phone numbers give multiple points to cross-reference and separates patients • date of birth and allergies should always be included • Physician information: Is it sufficient to determine that a licensed prescriber wrote the prescription? • contact information should be included • no prescription or medication order is valid without the signature of the prescriber
Prescription-Filling Process Safety Note A prescriber’s signature is required for a prescription to be considered valid.