november 8, 2008 1

MEDICATION
ERRORS
(MEDICATION USE SAFETY IN THE HOSPITAL)
OMAID HAYAT KHAN
LECTURER IN CLINICAL PHARMACY
THE UNIVERSITY OF LAHORE, PAKISTAN.
 The medication error may be classified
in to mistakes, slips, or lapses.
ERRORS
When actions are intended
but not performed

MISTAKES SKILL-BASED ERRORS (slips and lapses)

Errors in executing correctly planned
Errors in planning actions
actions

3. Action- 4.Memory-
1. Knowledge- 2. Rule-based based based
based errors Errors Errors (slips) Errors (lapsed)

2a. Good 2b. Bad rules 3a. Technical

errors
rules or failure
Misapplied To apply good
rules
Introduction

 There is always an inherent risk with the use of

medication in patient care
 This view is based on two concepts
1. Medications are inherently toxic (risk vs.
benefit)
2. Health care professionals are human and can
make mistake

(Remington The science and practice of pharmacy 21 st edition)

 Medication Errors

“The administration of wrong medication or dose of

medication to the wrong patient or at wrong time or
failure to administer the drug at specified time or
manner prescribed”
(Hospital pharmacy by William Hassan)

Medication errors, broadly defined as any error in the

prescribing, dispensing, or administration of a drug,
irrespective of whether such errors lead to adverse
consequences or not, are the single most preventable
cause of patient Harm.
NCC for MERP defines medication
error as

 “Any Preventable Event that may

cause or lead to inappropriate
medication use or patient harm
while the medication is in control
of Health care Professional“

 Such events are related to

1. Professional practice,
2. Health care products,
3. Procedures, and
4. Health care systems
 Medication Error
Statistics
 Since 1992, the FDA has received about
20,000 reports of medication errors
 It was indicated in the report of US institute of
medicine (IOM) committee in 1999 that between
44,000 and 98,000 deaths result each year from
medical errors in hospitals alone
 People die of medication errors are
more than that from workplace injuries.
 Even medication errors that do not
cause actual harm have a loss in term
of money in billions.
 contd

 US national data suggest that as many as 70%

of Adverse Drug Events (ADE) are due to
Errors, majority of which are preventable
 The next report of IOM in 2001 state
that health care system routinely fails
to deliver its potential benefits in term
of medication error prevention.
(Remington The science and practice of pharmacy 21 st edition)
Fact:
70%
of them were
preventable

• Non-compliance
• Inappropriate
prescribing
• Monitoring

• Cost of drug-related morbidity and

mortality in US outpatient $177
 Identifying Risks?

1. Medications are inherently toxic (risk vs.

benefit)

2. Health care professionals are human and can

make mistake

(Remington The science and practice of pharmacy 21 st edition)

What is an acceptable
Error rate?
 Center of Medicare and Medicad Services
suggested 2% error rate.
 Acceptable?
 How would patients feel about it?
 Would health care system reward staff for seriously
injuring only 30 people a year?

 Deming example: Following 99.9% safer system , US

would encounter:
 84 unsafe plane landings daily
 16000 lost pieces of mail per hour
 32000 bank check errors per day.
What if?

Source: Encyclopedia of Clinical Pharmacy by Joseph Dipiro.

Medication Errors in
Hospitals
Hospitals are intricate
localities where Medications
are handled by many
personnel of various
mindset therefore the
opportunities for error
abounds
 Contributing Factors to
Medication Errors
 Lack of adequate patient information
 Lack of drug information
 Miscommunication of drug orders
 lack of appropriate labeling
 Lack of adequate training
 Inadequate drug stations on pavilions
 Incomplete delivery of drugs
 Inadequate policies governing the
reporting of incidents
TALL-MAN Letters
 Hospital strategies for
Preventing Medication Errors
 Pharmacist intervention
 Computerized Physician Order Entry (CPOE):
 Set up CIVAS (unit dose dispensing)
 Establish an incident reporting system, revise
policies.
 Medication Error
Reporting
 If the error occurs but are not reported,
investigation and prevention strategies cannot
be developed
 Medication Error Report forms.
 These must be reported through Pharmacy to P
& TC to develop policies for their eradication.
Common Types
of
Medication Error
1) PRESCRIBING
ERRORS
PRESCRIBING ERRORS
 Prescribing Errors
(Contd)
 Most of OPD prescriptions do not contain age and
weight of patients
 Dosages of syrups/ suspension are written as 1 ¼
or 2/3 spoonful.
 Dosages of tablets are written as 1/3 tablet
Factors contributing to
Prescribing Errors
 Lack of Knowledge:
Prescribing without sufficient
evidence
 Aspirin is being prescribed in anti-inflammatory
doses even it is not recommended in pediatrics.

 Therapeutic use of Antibacterial in viral URTI.

 Use of Penicillin in Allergic patients.

 Use of Fluoroquinolones in patients with acute

bacterial sinusitis, uncomplicated UTIs, and
acute exacerbation of chronic bronchitis.
CONTRIBUTING FACTORS
(Contd):
• Lack of knowledge of the prescribed drug, its
recommended dose, and of the patient details contribute to
prescribing errors.

• Illegible handwriting.
• Inaccurate medication history taking.
• Confusion with the drug name.
• Inappropriate use of decimal points. A zero should
• Always precede a decimal point (e.g. 0·1). Use of a
trailing zero (e.g. 1·0)
• Use Preceding Zero & Avoid Trailing Zero.

• Use of abbreviations (e.g. AZT has led to confusion

between zidovudine and azathioprine).
Can you read this???

Neither can we!!!

Always use leading zeros for
decimal points. The order
should have read:

Digoxin 0.5 mg
 Recommendations for
Prescribing improvement
 Information of medication availability at the time of
prescribing

 Access to patient information at the time of prescribing

 Availability of dosing information at the time of prescribing

 Accuracy/ completeness of order by prescriber

 Applicability for the List of medication names that Look Alike-

Sound Alike (LASA)

 Electronic prescribing may help to reduce the risk of

prescribing errors resulting from illegible handwriting

 Computerized physician order entry systems eliminate the

need for transcription of orders by nursing staff
Electronic Prescription
Computerized physician
order
2) DISPENSING
ERRORS
 Dispensing Errors
 From the receipt of the prescription in the
pharmacy to the supply of a dispensed medicine to
the patient.
 This occurs primarily with drugs that have a similar
name or appearance.
 Dispensing Zinnat (Cefuroxime) instead of
Zincat (Elemental Zinc)
 Dispensing of Ventolin instead of Vidaylin
 Dispensing of Gentamycin instead of Gentian
violet.
 Lasix ® (frusemide) and Losec® (omeprazole)
 Other potential dispensing errors include wrong
dose, wrong drug, or wrong patient
Recommendations for
Dispensing
 Dispensing services should be
evaluated for
 Work environment, workload, hours of operation,
Inventory management,
 Ensuring a safe dispensing procedure.
 Separating drugs with a similar name or
appearance.
 Awareness of high risk drugs such as potassium
chloride and cytotoxic agents
 Emphasis should be given on
 Patient education, patient counseling
3) ADMINISTRATION
ERROS
 Administration Errors
 Discrepancy occurs between the drug received
by the patient and the drug therapy intended by
the prescriber
 Dosage at TDS interval are not given with a gap
of 8 hrs.
 Error: Vincristine and L- Asparaginase are
administered together in the regimen of ALL
 Error: Taking of zinc sulphate (sachet) just after
penicillin antibiotics have been administered
 Incorrect administration technique and the
administration of incorrect or expired
preparations
CONTRIBUTING FACTORS TO DRUG
ADMINISTRATION ERRORS
Recommendation for
Administration
 Safe administration is a team effort (double checking)
 Dose calculation and verification
 Identification of patient
 Ensuring that the prescription, drug, and patient are in
the same place in order that they may be checked
against one another
 Timing of administration in context with other drugs
 Preparation and dispensing of drugs
 Proper use of medication devices
 Documentation of treatment
 Errors in Labeling

 Ventolin injection was labeled as

dexamethasone
 Dexamethasone injection was labeled as
vitamin K.

(emergency ward 24/09/2008)

Lack of confidence on Local
brands of drugs
 Havingno trust on local brands of
drugs often prescribes overdoses of
drugs available in the hospital.
 Doseof lorich (Loratidine) was
prescribed as twice and thrice a day
Errors in Reconstitution and
Dilution of drugs

 Wrong procedure is followed while

reconstitution of injectable
 As they are diluted directly with
saline.
 Nursing staff usually shakes the
solution vigorously for dispensing.
 Displacement of dry powder is not
considered while diluting injection.
 Recommendations for
Dilution
 Correct method is that if dilution is to be made with saline or
any other diluent, the initial reconstitution should be made
with WFI.
 Then this solution should be added to diluents
 Dry powder Medication is dissolved by gentle rotation
 Use chart that contain displacement of different dry powders
with solvents
Physical
incompatibilities of
Diazepam.

Fig. 1a: Chemical precipitation of

Midazolam (turbidity) and
Ketamin (particle formation)
 Errors in Storage of
Reconstituted Drugs

 Mostlydate and time is not

mentioned on injections after
reconstitution.
 Thiswill cause problems in
determining stability of reconstituted
medicines
 Labeling of Reconstituted Drugs must
bear date & time of reconstitution
Errors in Aseptic Handling of
IV fluids
 IVfluid bottles are punctured and
then left as such and used later
on for dilution without caring for
their asepsis.
 Ampoules are broken and kept
with cotton plugs (Penicillin G)
Overdose/ Underdose
Errors
 Mostly the doses of drugs are not adjusted
according to renal status of the patient.
 Drug-drug, drug-food, drug-disease
interactions.
Omission of dose Errors

 Because of delayed entry on chart or non-

availability of drug sometimes dose is omitted.
 Wrong dose Errors

 Antimalarial drugs (caution be taken in

arrhythmic patients)
 Syrup Albandazole (100mg/5ml) prescribed as 2
spoons daily for 15 days.
 Majority of patients are prescribed b.d or t.d.s
dose of Loratidine (syrup)
 Dose of Benzyl-penicillin written as 1 ½ vial
Errors in Prescriptions of Anti-Ulcer Drugs

Mostly omeprazole/ cimetidine are prescribed along with

Antacids without giving any direction for use.

These anti acid drugs are not directed to take before/ after
meals.
Errors in Disposal of
Disposables
 IV lines are not disposed off timely
FUTURE STRATEGIES
 Future Strategies
 Medication Error Reporting (MER) system
 The institution use incident report to track incident pattern and to
initiate quality, improvement programs as needed

 Develop policies/ procedures of working and treatment plans

 Follow formulary based prescribing (prescription format)

 Physician, Pharmacist and Nurses should work in coordination

with a common object of improving the patient outcome.

 Expand the role of Pharmacy in term of prescription

checking, medication preparation (CIVAS) and drug
information.
Overlap of Core Competencies
of Health Professionals
 CRITICAL THINKING
You have given Mrs Veena her What
medication including cough Elixir. would
She asks you ,Now you didn’t you do ?
give me any Codeine ,did you? I
am allergic to it .
 You reply that there is no codeine
in her medication.
 After returning to the medication
room, you think again and
recheck the bottle of the cough
elixir and find that it contains
Codeine.
 STEPS TO BE TAKEN IN
PREVENTING MEDICATION
ERROR
•Follow the rights of
medication administration
•Right patient
•Right drug
•Right dose
•Right time
•Right route
•Right recording
•Right assessment
•Right education
•Right evaluation
•Right to refuse medication
 Double check all calculation, even simple calculation
 Do not allow any other activity to interrupt your
administration of medication to a client.
 Routinely refer to drug interaction charts or drug reference
source and commit common interactive drugs to memory.
 Do not use any unstandard abbreviation and symbols,
question if any one use
 Read the leaflet of the drug carefully when giving new
drug first time.
 Do not make assumptions of illegible orders.
 Do not accept incomplete orders and telephonic or verbal
orders.
 Double check with a client who has allergies about all new
drugs as they are added in treatment plan
 Question a drug form used in unfamiliar way.
 Document all medication as soon as they are given.
 When you have made an error reflect on what went
wrong ,ask how you could have prevented the error
 Evaluate the context for any medication error to determine if
nurses have the necessary resources for safe medication
administration.
 When repeated medication error occurs within a work area,
identify and analyze the factors that may have caused the
errors and take corrective action.
 Attend in-service program that focus on the drug you
commonly administer.
Questions?