CHAPTER 12 MEDICATION SAFETY Created by Jennifer Majeske, Mineral Area College

Created by Jennifer Majeske, Mineral Area College

C H A P T E R 1 2

MEDICATION SAFETY


LEARNING OBJECTIVES

• Understand the extent of medical and medication errors and their effects on patient health and safety.

• Identify specific categories of medication errors.• Discuss examples of medication errors commonly

seen in pharmacy practice settings.• Apply a systematic evaluation to search for

medication error potential to a pharmacy practice model.

• Define strategies, including the use of automation, for preventing medication errors.

• Identify the common systems available for reporting medication errors.


INTRODUCTION

• Pharmacy technicians play a crucial role in the prevention of medication errors.• Pharmacy personnel work to establish safe

practices and promote safety during the prescription-filling process.• Medication error reporting systems have been

developed by: the FDA, the USP and the Institute for Safe Medication Practices (ISMP).• Automation is one solution has clearly been

shown to reduce medication errors.


MEDICAL ERRORS

• Medical error: any circumstance, action, inaction, or decision related to health care that contributes to an unintended health result.• What are some examples of a medical error?• Medical errors are often times difficult to define,

because the circumstances that cause them are infinite.


SCOPE AND IMPACT OF MEDICAL ERRORS

• Medical-related lawsuits helps provide a sense of the scope of medical errors in the U.S.• Examining only medical errors that occur during

hospitalization approximately 98,000 people die each year as a result of medical errors in the U.S.• The 6th leading cause of death in the United

States.• There are more preventable deaths from medical

errors than from diabetes, Alzheimer’s disease, pneumonia, influenza, and kidney disease.


MEDICATION ERRORS

• Medication error: “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 the professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.” (The National Coordinating Council for Medication Error Reporting and Prevention)


SCOPE AND IMPACT OF MEDICATION ERRORS

• Medication errors are the more common medical errors.• From hospital studies, medication-related error deaths

are approximately 7,000 per year.• Drug errors caused an estimated 400,000 preventable

errors in the hospital with twice as many in nursing homes.

• Medication errors in a community pharmacy are estimated at 1.7% of all prescriptions dispensed; 4 out of 250 prescriptions contains an error of some type.

• Pharmacy technician’s need to be on constant lookout for possible errors and adopt safety-oriented practices when working with patients.


PATIENT RESPONSE

• Most patients benefit from a medication and its intended therapeutic response.• Unique physical and social circumstances, for

individual’s make it impossible to predict the medication errors that may cause harm.


PHYSIOLOGICAL CAUSES OF MEDICATION ERRORS

• Each patient has a unique response to medication.• Each person is genetically unique; the speed at

which a medication is eliminated from the body varies greatly.• Even if a patient lacks a certain enzyme that

helps remove a drug from the body, resulting in serious harm, the result is it is considered a medication error.• Technicians must pay special attention to

computer software alerts.


PHYSIOLOGICAL CAUSES OF MEDICATION ERRORS

• Age-related decrease in kidney function, is a physiological cause.• Many medications rely on kidney function to

eliminate drugs from the body.• If the dose of a drug is not lowered, the drug could

build up to toxic levels, causing a medication error.• How can a technician help a pharmacist avoid

medication errors that might affect the kidneys?


SOCIAL CAUSES OF MEDICATION ERRORS

• Patients can contribute to medication errors through incorrect self-administration.

• Social causes of medication errors include failure to follow instructions because of cost or noncompliance, failure to take therapy as instructed, or misunderstanding of instructions.

• 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; not following directions; terminating the drug regiment too soon.


SOCIAL CAUSES OF MEDICATION ERRORS

• Social causes can result in adverse drug reaction, subtherapeutics or even a toxic dose.• Over 50% of patients on necessary long-term

medications are no longer taking them after 1 yr.• Noncompliance could result in a progression of a

disease, lasting harm or death.• Issues of noncompliance should be brought to the

attention of the pharmacist.• Social circumstances create the potential for

medication errors.


CATEGORIES OF MEDICATION ERRORS

• Omission error: when a prescribed dose is not given.

• Wrong dose error: a dose is either above or below the correct dose, more than 5%.

• Extra dose error: a patient receives more doses than prescribed.

• Wrong dosage form error: dose formulation given is not the accepted interpretation of the doctors order.

• Wrong time error: when any drug is given 30 minutes or more before or after it was prescribed; does not include prn (as needed) orders.


CATEGORIES OF MEDICATION ERRORS

• Categories of medication errors can also be defined by what caused the failure of the desired result.• Human failure: occurs at an individual level.• Technical failure: results from equipment

problems.• Organizational failure: occurs because of

deficiency in organizational rules, policies or procedures.


ROOT-CAUSE ANALYSIS OF MEDICATION ERRORS

• Root-cause analysis: a logical and systematic process used to help identify what, how and why something happened in order to prevent it from happening again.

• Three of the most common causes of medication errors are:(1) Assumption error: an essential piece of information cannot be verified.(2) Selection error: when two or more options exist and the wrong option is chosen.(3) Capture error: when focus on a task is diverted elsewhere.


PRESCRIPTION-FILLING PROCESS IN COMMUNITY AND HOSPITAL PHARMACY

PRACTICE• Outlining work tasks in a step-by-step manner

can be a helpful way to review potential causes of medication errors.• It is important to remember for both the

pharmacist and the technician that safety cannot be compromised for speed.• Fig 12.1• Work practices, when broken into individual steps,

can be reviewed to determine what information is necessary to complete that step and what resources are needed to verify the information.


PRESCRIPTION-FILLING PROCESS IN COMMUNITY AND HOSPITAL PHARMACY PRACTICE

• Think of each step in three parts: • (1) information that needs to be obtained or

checked • (2) resources that can be used to verify

information• (3) potential medication errors that would result

from a failure to obtain or check the necessary information using the appropriate resources


STEP 1: RECEIVE AND REVIEW PRESCRIPTION

• Table 12.1 Step 1: Receive and Review Prescription• Basic Review of Prescription: Can you read and

understand the prescription?• Verbal Order Precautions: Clarify orders before

entering into the computer system.• Validity of Prescription: Is the prescription valid

and legal?• Detailed Review of Prescription: three basic types

of information need to be reviewed: prescriber information, patient information, and medication information.


STEP 1: RECEIVE AND REVIEW PRESCRIPTION

• Prescriber Information: sufficient to determine whether a licensed and qualified prescriber wrote the prescription.

• Patient Information: should include enough detail to ensure that unique individuals can be pinpointed.

• Medication Information: should include the drug name, strength, dose, dosage form, route of administration, refills or length of therapy, directions for use, and dosing schedule.

• Prescribing Errors: poor handwriting, nonstandard abbreviations, confusing look-alike and sound-alike drugs, and “as directed” instructions.


STEP 2: ENTER PRESCRIPTION INTO COMPUTER

• Table 12.2• Accurate Data Entry: the ability to accurately enter

prescription information into a computer system can mean the difference between a patient receiving the correct medication, serious harm or death.

• Potential Dangers: does the form or formulation match the route of administration?

• Depo-Medrol• Injectable• IM administration• Cloudy suspension (when reconstituted)

• Solu-Medrol• Injectable• IV administration• Clear solution


STEP 2: ENTER PRESCRIPTION INTO COMPUTER

• Teaspoons vs. Milliliters: use milliliters to minimize errors in order entry and labeling.• Formulation Mix-Ups: morphine sulfate (20

mg/mL) and (10 mg/5 mL or 2 mg/mL); ointments vs. creams; solutions vs. suspensions; substituting a capsule for a tablet.• Precautions with Scheduled Drugs: when entering

certain Schedule II drugs.• The information entered into the computer

database should be checked against the original prescription.


STEP 3: PERFORM DRUG UTILIZATION REVIEW AND RESOLVE MEDICATION ISSUES

• The potential for medication errors increases with the number of medications a patient takes.

• Table 12.3• Drug Utilization Review (DUR): for every prescription;

checks for multiple drug therapy, dosing ranges, existing allergies, pertinent medical diseases, and conditions.

• Dosing Ranges and Drug Interactions: a DUR should be performed by the pharmacist.

• Allergy-Related Alerts: a DUR will often prompt and allergy-related question that needs to be addressed by the pharmacist.

• Pharmacist Follow-up: the pharmacist must decide whether to counsel or contact the physician before filling a prescription.


STEP 4: GENERATING PRESCRIPTION LABEL

• Table 12.4• Check the printed label with the original

prescription.• Is the correct patient name on the label?• Is the drug, dose, concentration and route

identical to those indicated on the original prescription?


STEP 5: RETRIEVE MEDICATION

• Table 12.5• Safety Practices for Accurate Drug Selection: use NDC

numbers, drug names and other information supplied by the manufacturer to secure the correct drug.

• NDC Numbers: use the NDC number to cross-check a medication because each NDC number is specific .

• Heparin Safeguards: several serious medication errors have occurred when the wrong concentration of heparin was administered.

• Look-Alike and Sound-Alike Labels: can lead to medication errors and possible adverse drug reactions; Troppi vs. Scarf.

• Product line extension – using a brand name to sell various combinations of active ingredients with different indications.


STEP 6: COMPOUND OR FILL PRESCRIPTION

• Table 12.6• Safety Practices for Accurate Compounding and

Filling: calculation and substitution errors are frequent sources of medication errors in the pharmacy.

• Interruptions and distractions during filling or compounding can lead to medication errors.

• Equipment Maintenance: equipment used in compounding should be maintained, cleaned and calibrated on a regular basis.

• Auxiliary labels: serve as reminders of the most crucial aspects of proper medication administration.


STEP 7: OBTAIN A PHARMACIST REVIEW AND APPROVAL

• Table 12.7 The pharmacist must be the one to review and approve a prescription.• Responsibilities of the Pharmacist: the pharmacist

is legally responsible for verifying the accuracy and appropriateness of the prescriptions filled.• Pharmacist verify the quality and integrity of the

end product; it is not very productive to have them verify each step in the process.• Role of the Technician in Verification Process:

practice checking the work of a colleague.


STEP 8: STORE COMPLETED PRESCRIPTION

• Table 12.8• Proper Storage Conditions: medication integrity,

and being able to ensure that is an important part of medication safety.• What sorts of problems can arise if medications

are not stored properly?• Organizational Systems: order and organization

can help keep patient’s medications together and separate from other patients.


STEP 9: DELIVER MEDICATION TO PATIENT

• Table 12.9• Verification of Patient Identity: how can you as a

technician verify that the right prescription is being given to the right patient?• Explanation of Medication to Patient: double-

check the number of medications the patient expects; encourage the patient to ask questions.• “Show-and-Tell” Technique with Patient: what

advantages are there to the “show-and-tell” technique?


STEP 9: DELIVER MEDICATION TO PATIENT

• ISMP’s “Tell-Back” System: “tell-back” approach uses patient-centered, open-ended questions to determine patient understanding.

• Nursing Unit Delivery of Medication: adding the caregiver to the medication delivery process add an additional person to confirm the accuracy and appropriateness of the medication.

• The technician is in the best position to discover potential errors.

• Communication and cooperation with nurses, physicians, and other members of the health care team safeguards the patient’s well-being.


MEDICATION ERROR PREVENTION

• The most common error in dispensing and administration is drug identification.• The pharmacy technician has the most

opportunities to cause and prevent medication errors.• Prescribers should ensure the “five Rs”• Right drug• Right patient• Right strength• Right route• Right time


THE RESPONSIBILITY OF THE HEALTHCARE PROFESSIONALS

• “First do no harm.”• The profession of pharmacy exists primarily to

safeguard the health of the public.• Healthcare workers must focus on treating the

patient, ensuring the best possible outcome by the safest means possible.• No acceptable medication error exists.• Filling medication orders should be done with a

100% error-free goal in mind.


POTENTIAL SOURCE OF ERRORS

• Technicians can assist in ensuring safety when it comes to medications.• How can we as technicians assist in ensuring

safety?• Technicians to reduce potential medication errors

should assume more routine dispensing tasks.• Northwestern Memorial Hospital in Chicago• 1/3 of patients’ charts contained medication errors• 85% originated when hospital personnel took incomplete

medication histories

• Table 12.10 General Tips for Reducing Medication Errors


PATIENT EDUCATION

• Patients and caregivers need the basic knowledge to administer, handle and support safe medication use.• Encourage patients to ask questions.• Patients who ask questions can connect with the

pharmacist, or appropriate healthcare provider.• Patients should understand the ten key pieces of

information about every medication taken; Table 12.11.


INNOVATIONS TO PROMOTE SAFETY

• Many efforts have been made by all healthcare team members to minimize the possibility of medication errors.

• Workplace Ergonomics: work setting contributes to overall safety of the work environment.

• Table 12.12 Work Ergonomics Practices to Promote Safety

• Package, Medication, and Label Design: drug manufacturers and pharmacies are developing innovative product and package designs.

• Package Design: what has Target done to minimize medication errors?


PACKAGE, MEDICATION, AND LABEL DESIGNS

• What other things can be done in a pharmacy to help minimize medication errors?• Medication Design: unique colors, shapes, or

markings; the four middle numbers of the NDC are larger font or boldface type.• Label Design: “tall man” or enhanced lettering,

adding warning statements or other labeling changes to better differentiate products and dosages.


USE OF AUTOMATION

• Many human errors are prevented by using automation.• Electronic Prescribing: e-scripts are increasingly being used

by physicians to send prescriptions to pharmacies.• Bar-Coding Technology: the scanned bar code is compared

against the verified prescription information.• Integrated, Automated System: medication errors have

been reduced by more than 50%.• Electronic medication administration record (eMAR)

– documents administration of a medication electronically rather than on paper.

• Technological advances empower productivity on behalf of the technician; allowing the pharmacist to be more involved with patient care.


PROFESSIONAL PREVENTION STRATEGIES

• American Society of Health-System Pharmacists (ASHP) has developed the Pharmacy Technician Initiative.• This initiative enhances education and training of

pharmacy technicians.• Improving patient safety and minimizing

medication errors.• ASHP-accredited pharmacy technician training

programs and PTCB certification.• Results are a more highly qualified workforce for

the future.


PERSONAL PREVENTION STRATEGIES

• Take care of yourself. Take care of your patients.• Healthcare Provider Service Organization (HPSO)

recommends some ways to take care of yourself to combat fatigue and help prevent errors.• What are some of the suggested lifestyle

recommendations?


MEDICATION ERROR REPORTING SYSTEM

• The first step of preventing medication errors is to collect information and identify problems.• What would prevent you from reporting an error?• Would the existence of an anonymous or no-fault

system change the reason for not reporting an error?


STATE BOARDS OF PHARMACY

• Many states have mandatory error-reporting systems.• Most states do not punish pharmacist for errors so

long as a good faith effort was made to fill correctly.• http://www.fda.gov/Drugs/ResourcesForYou/Consumer

s/ucm143553.htm• Error Reporting: best performed by the pharmacist;

technicians are an integral part of the process of error identification.

• Informing the patient that there has been a medication error is a most delicate process. Patients should understand the nature of the error, effects the error may have, and how to prevent future errors.

• Please help the profession by reporting errors.

http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm

http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm


THE JOINT COMMISSION

• Sentinel Event Policy created by the Joint Commission in 1996 – centralized point to error-reporting.

• Sentinel event: an unexpected occurrence involving death, serious physical or psychological injury, or the potential for such occurrences to happen.

• Accreditation and Medication Safety: • The Institute of Safe Medication Practices (ISMP) recommends

(1) the elimination of certain abbreviations (2) the education of healthcare professionals regarding frequently confused drug names.

• Safety programs to improve communication; implement policies prohibiting use of non-approved abbreviations; and policies requiring computer checks and balances.

• It’s so much more than just placing blame on an individual.


SPEAK UP CAMPAIGN

• Design for consumers to take a more active role in their health care and minimize misunderstandings that may lead to medication errors.

• http://www.youtube.com/watch?v=EccuE-_2_2E• http://www.youtube.com/watch?v=3q3thYvsYK8• Speak up.• Pay attention.• Educate yourself.• Ask for an advocate.• Know what medications you’re taking.• Use a hospital, clinical, surgery center that’s been

checked out.• Participate.

http://www.youtube.com/watch?v=EccuE-_2_2E

http://www.youtube.com/watch?v=EccuE-_2_2E

http://www.youtube.com/watch?v=3q3thYvsYK8

http://www.youtube.com/watch?v=3q3thYvsYK8


UNITED STATES PHARMACOPEIA

• MEDMARX Reporting System: MEDMARX - allows institutions and healthcare professionals to anonymously document, analyze, track, and trend adverse events.

• Since 1998, MEDMARX has received over 1.2 million reports of medication errors.

• Most recent MEDMARX report: • 26,604 medication errors• 1.4% caused patient harm• 7 deaths• +60% of medication errors occurred during the dispensing

process• 38.5% of the time pharmacy technicians were involved


INSTITUTE FOR SAFE MEDICATION PRACTICES

• Institute for Safe Medication Practices (ISMP): nonprofit healthcare agency whose membership is composed of physicians, pharmacists, and nurses.• ISMP mission statement: “to understand the

causes of medication errors and to provide time-critical error reduction strategies to the healthcare community, policy makers and the public.”



• Medication Errors Reporting Program: Medication Error Reporting Program (ISMP MERP) - this program is designed to allow healthcare professionals to report medication errors directly.

• Medication errors include:(1) Incorrect drug, strength, or dose(2) Confusion over look-alike and sound-alike drugs(3) Incorrect route of drug administration(4) Calculation or preparation errors(5) Misuse of medical equipment(6) Errors in prescribing, transcribing, dispensing, or monitoring

medications.



• Other ISMP Initiatives:• ISMP makes recommendations to minimize

dispensing errors.• What other recommendations are made by the

ISMP?• Pharmacists and technicians are taught to check

a prescription at least four times.• The ISMP has sponsored national forums on

medication errors; the Joint Commission has adopted many ISMP recommendations.


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CHAPTER 12 MEDICATION SAFETY Created by Jennifer Majeske, Mineral Area College