MEDICATION ERRORS Patients depend on health systems and health professionals to help them stay healthy. As a result, frequently patients receive drug therapy with the belief that these medications will help them lead a more healthy life. But there are many drug related challenges at various levels, involving prescriber, pharmacists and patients. Errors in medication use process, including errors in medication prescribing, dispensing, administering and monitoring are responsible for a significant number of drug-related deaths. While medication misadventure can occur anywhere in the health care system from prescriber to dispenser to administration and finally to patient use, the simple truth is that many errors are preventable, and pharmacists assume active role in appropriate use of drugs. What is a medication error? A medication error is any error in the medication process, whether there are adverse consequences or not. Most errors occur during the administration stage followed by prescription, preparation, and transcription. Nurses and pharmacists intercept up to 70% of prescription errors. Preparation errors occur when there is a difference between the ordered amount or concentration of a medication and what is actually prepared and administered. The industry standard for pharmaceutical preparations is a concentration difference of less than 10%. However, approximately two thirds of infusion prepared by nurses are outside industryaccepted standards and 6% contain a greater than two fold concentration error. Transcription errors are usually attributed to handwriting, abbreviation use, unit misinterpretation ( mg for mcg ), and mistakes in reading. Definition: An error is A failure to perform an intended action that was appropriate under the given circumstances. Medication errors is defined as Any preventable event that may cause or lead to an inappropriate medication use or patient harm while in the control of the health care professional, patient or consumer. The American National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) define: 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 healthcare professional, patient, or consumer. Such events may be related to professional, patient, or consumer. Such events may be related to professional practice, healthcare Mrs. Parminder Ratan, Asst. Professor, Department of Pharmaceutical Sciences Page 1
SHRI GURU RAM RAI INSTITUTE OF TECHNOLOGY AND SCIENCE products, procedures and systems including prescribing, order communication, product labeling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use. A medication error can also be broadly defined as A dose of medication that deviates from physian s order as written in the patient s chart or from standard hospital policy and procedures Classification: The most common way to classify errors is to identify them by type. American Society for Hospital defines different categories of medication errors based on the type of error. Fig: Types of Medication Errors Mrs. Parminder Ratan, Asst. Professor, Department of Pharmaceutical Sciences Page 2
Table 1. Types of Medication Errors Prescribing error Prescribing error may be defined as the incorrect drug selection for a patient. Such errors can include the dose, quantity, indication, or prescribing of a contraindicated drug Omission error The failure to administer an ordered dose to a patient before the next scheduled dose, if any. Wrong time error Administration of medication outside a predefined time interval from its scheduled administration time (this interval should be established by each individual health care facility). Unauthorized drug Administration of the patient of medication not authorized by a error legitimate prescriber for the patient. Improper dose error Administration to the patient of a dose that is greater than or less than the amount ordered by the prescriber or administration of duplicate doses to the patient, i.e., one or more dosage units in addition to those that were ordered. Wrong dosage-form error Administration to the patient of a drug products in a different dosage form than ordered by the prescriber Wrong drug Drug product incorrectly formulated or manipulated before prescription error administration. Wrong administrationtechnique In appropriate procedure or improper technique in the administration of a drug. error Deteriorated drug Administration of a drug that has expired or for which the physical or error chemical dosage-form integrity has been compromised. Monitoring error Failure to review a prescribed regimen for appropriateness and detection of problems, or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy. Compliance error Compliance errors occur when patients use medications inappropriately. Mrs. Parminder Ratan, Asst. Professor, Department of Pharmaceutical Sciences Page 3
Causes for medication errors: The majority of medication errors do not occur in emergency situations but while performing routine clinical tasks. The source of these errors can lie at any stage of the process from the initial prescription of medication to its administration. Incomplete patient information (not knowing about patients allergies, other medicines they are taking, previous diagnoses, and lab results) Unavailable drug information (such as lack of up-to date warnings) Inexperienced or inadequately trained staff Miscommunication of drugs orders, which can involve poor handwriting, confusion between drugs with similar names, misuse of zeros and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations. Factors such as similar product name or packaging from pharmaceutical companies. Lack of appropriate labeling as a drug is prepared and repackaged into smaller units Environmental factors, such as lighting, heat, noise, and interruptions that can distract health professionals from their medical tasks. Workplace environmental problems increasing the job stress Excessive task demand leads to high work overload for staff. Work shift-more errors occur during the night Lack of patient couseling cause lack of patients understanding of their therapy Too many telephone calls Too many customers Lack of concentration Staff shortage Misinterpreted prescription Poor drug distribution practices. Access to drugs by non-pharmacy personnel Dose miscalculations Medication error reporting system: Intensive Monitoring System- If refers to a continuous detection of medication error in hospital via prescription auditing. Intensive monitoring system focuses on prescription auditing as prescription is the first step in the treatment of patient. Mrs. Parminder Ratan, Asst. Professor, Department of Pharmaceutical Sciences Page 4
Intensive monitoring system is the best because it is always better to detect the error at the very basic step before it reaches to the patient. Spontaneous Reporting System- It means that it is the responsibility of each clinical staff to inform the concern department immediately after any adverse drug reaction or any kind of medication error. Medication Error Prevention: Patient Education Health care professionals must provide adequate patient education about the appropriate use of their medications as part of any error prevention program. By giving education about medication, patients can act as the final check in the system. When patients take an active and informed role in his or her health care, many errors can be prevented. Examples of instructions to patients that can help prevent medication errors are: Know the names and indications of your medications Read the medication information sheet provided by your pharmacists Do not share your medications Check the expiration date of your medications and dispose of expired drugs Learn about proper drug storage Keep medication out of the reach of children Learn about potential drug interactions and warnings Prior Authorization Prior authorization programs are used by managed health care systems as a tool to assist in providing quality, cost-effective prescription drug benefits. Improving patient safety by promoting appropriate drug use is an integral function of prior authorization programs. Medication errors can be reduced by prior authorization systems in various ways. Prior authorization may be used to protect against adverse events in highly contraindicated populations. Example: A prior authorization program employed to ensure that patients do not receive certain drugs, such as antibiotics, for exceedingly long durations that could put patients at increased risk for adverse events. Bar Code, bedside care systems: Electronic technology is one of the way of improving patient safety and reduce medication Mrs. Parminder Ratan, Asst. Professor, Department of Pharmaceutical Sciences Page 5
Errors, through the use of standard machine-readable codes ("bar codes"). Medication bar coding is a tool that can help ensure that the right medication and the right dose are administered to the right patient. Bar code systems are particularly suited for efficient and accurate checking functions that occurs when medication are dispensed and administered could be done more efficiently and accurately if aided by bar code scanning. This application would include having bar codes on the package of each medication dispensed and administered, on a patient identifier and on the person dispensing and administering the dose. Bar code system can be linked to clinical information and medication profile, so that when the dose is dispensed and administered to a patient, an automatic check could be made to ensure that the drug was prescribed for correct patient, the dose, time and route of administration is correct, and that the patient does not have an allergy to the medication being dispensed and administered. Moreover performance measurement system eg: late doses and omitted could automatically be tracked, reducing the dependence on voluntary reporting or observational based studies. Electronic Prescription Record: An electronic prescription record (EPR) contains all the data legally required to fill, label, dispense and/or submit a payment request for a prescription. Pharmacists use the record as a tool to reduce medication errors by guarding against drug interactions, duplicate therapy and drug contraindications. The EPR can also help reduce medication errors by helping pharmacists monitor and audit utilization and by facilitating communication between health care providers to improve patient care. E-prescribing This is a computer application that utilizes electronic prescribing by entering orders on a computer, known as Computerized Physician Order Entry (CPOE), is a technology that could help prevent many medication errors. CPOE systems allow physicians to enter prescription orders into a computer or other device directly, thus eliminating or significantly reducing the need for handwritten orders. E-prescribing and CPOE can reduce medication errors by eliminating illegible and poorly handwritten prescriptions, ensuring proper terminology and abbreviations, and omitted information. More advanced CPOE software incorporates additional safety features that allow the physician to have access to accurate patient information, including patient demographic information such as age, medication history and medication allergies. Mrs. Parminder Ratan, Asst. Professor, Department of Pharmaceutical Sciences Page 6
Electronic DUR Pharmacists are able to conduct prospective online drug utilization reviews (DUR) due to the technology of the electronic prescription record. The online DUR process allows the Pharmacist to conduct a review of the prescription order at the time of filling. This technology allows the pharmacist to assess the prescription order at the time of dispensing and, using information from the patient s medical and/or pharmacy record, determine the appropriateness of the prescribed medication therapy. Medication safety issues commonly addressed in an online DUR process include the following: Drug-disease contraindications Drug-drug interactions Incorrect drug dosage Inappropriate duration of drug treatment Drug-allergy interactions Clinical abuse or misuse Automated Medication Dispensing Automated medication dispensing systems are now widely used as a less labor-intensive method of dispensing medications. Automated pharmacy dispensing systems are more efficient at performing pharmacists tasks that require tedious, repetitive motions, high concentration and reliable record keeping, which can all lead to medication dispensing errors. When utilized appropriately, automated medication dispensing systems help to reduce medication errors and improve patient safety. Many automated dispensing systems utilize the bar coding technology. Conclusion: Medication errors are part and a serious problem in the health care system. Recognition of the problem is one of the important step to minimize the occurrence of medication errors. Pharmacist has responsibility of ensuring the safe and effective use of medications by minimizing the medication errors. They must take the lead role in the medication use process. Pharmacist need to contribute in improving patient care by actively participating and pursuing improvements in the medication use process. Thus pharmacists and other health care professionals involved in the medication use process must work together to develop a systems approach to reduce medication error. Mrs. Parminder Ratan, Asst. Professor, Department of Pharmaceutical Sciences Page 7
Reference: 1. Academy of Managed Care Pharmacy, The Academy of Managed Care Pharmacy s Concepts in Managed Care Pharmacy, Medication error, http://www.amcp.org/workarea/downloadasset.aspx?id=9300. (accessed on 22 May 2016) 2. Bonnie J et al. Development & validation of medication administration error reporting survey. Advances in Patient Safety: From Research to Implementation, 2005: 4; 457-476. 3. Moyen E et al. Review Clinical review: Medication errors in critical care. Critical Care, 2008: 12(2); 1-7 4. http://www.nccmerp.org/sites/default/files/fifteen_year_report.pdf/22 (accessed on 22 may 2016) 5. Parthasarathi G et al. A textbook of Clinical Pharmacy Practice, Second edition. Universities Press, 2012, chapter 28, Medication errors and adverse drug events:486-501. 6. Sudheer K D et al. Fundamentals of clinical pharmacy practice. PharmaMed Press, 2010, chapter 13, Medication errors: 233-247. 7. Roy V et al. Medication errors: causes & prevention. Health Administrator, 19(1); 60-64. Mrs. Parminder Ratan, Asst. Professor, Department of Pharmaceutical Sciences Page 8