Post on 14-Aug-2015
MEDICATION ERROR
AGA KHAN HOSPITAL (22-JAN-2014)
Presentation By: Beenish Iqbal Arain
Objectives
Definitions Causes Stages of Medication error How to decrease Medication error
Dr:Beenish Iqbal Arain
Medication Error Definition Medication errors, broadly defined as any error in
the prescribing, dispensing, or administration of a drug,
Medical errors are often described as human errors in healthcare
> Such events may be related to:1) professional practice
2) health care products
3) Procedures and systems
4) product labeling, packaging, and nomenclature
5) dispensing
6) distribution
7) administration
8) education
9) monitoring
Dr:Beenish Iqbal Arain
Some reasons errors occur verbal orders poor communications within healthcare team poor handwriting improper drug selection missing medication drug interactions availability of floor stock (no second check) look alike / sound alike drugs hectic work environment lack of computer decision support
Dr:Beenish Iqbal Arain
Stages of Medication Error Phase 1- Ordering/Prescribing Phase 2- Dispensing Phase 3- Administration Phase 4- Monitoring
DR:Beenish Iqbal Arain
Ordering/prescribing
inadequate knowledge about drug indications and contraindications
not considering individual patient factors such as allergies, pregnancy, co-morbidities, other medications
wrong patient, wrong dose, wrong time, wrong drug, wrong route
inadequate communication (written, verbal) documentation - illegible, incomplete, ambiguous mathematical error when calculating dosage incorrect data entry when using computerized
prescribing e.g. duplication, omission, wrong number
DR:Beenish iqbal Arain
Prescription error example
Dispensing
inexperience rushing doing two things at once interruptions fatigue, boredom, being on “automatic pilot”
leading to failure to check and double-check lack of checking and double checking habits poor teamwork and/or communication
between colleagues Too much phone calls Dr:Beenish Iqbal Arain
Dispensing error example
Look alike/ sound alike
Sound alike Look alike
Zantac/Zyrtec Rotavir/Ritnovir Folic acid/ Folinic acid ephederine/ epinephrine Doxorubicin/
Daunorubicin Celebrex/ cerebryx
DR:Beenish iqbal Arain
Cyclogest/paracup
Look alike examples
Administration
wrong patient wrong route wrong time wrong dose wrong drug omission, failure to administer inadequate documentation
Administration error example
Monitoring
lack of monitoring for side-effects drug not ceased if not working or
course complete drug ceased before course completed drug levels not measured, or not
followed up on communication failures
Dr:Beenish Iqbal Arain
What Can You Do To Decrease Medication Errors?
Check and double check, if in doubt check it out, again!
Follow the 5 R’s: right patient, right drug, right dose, right time, right route
Never assume, “pharmacy put the medication in the drawer so this must be right”, pharmacy makes errors too.
Never assume, “the resident ordered this large dose so it must be right”, Residents make errors too.
Know the correct mg/kg dose of medications you are administering.
Know why you are giving the medication, the expected action, and any potential side effects.
DR:Beenish Iqbal Arain